Improving efficiency & maximizing potential

EHRs: Improving efficiency & maximizing potential This E-Book is brought to you by e-book Digital publication Important information about EHRs from the publishers of Medical Economics

EHRs: Improving efficiency & maximizing potential As the evolution of health information technology forges forward, electronic health record (EHR) systems will continue to transform the practice of medicine. Tomorrow s practice won t be confined by four walls and 15-minute appointment slots, but will have the ability to influence, guide and educate patients in real-time at home or at work while changing the way healthcare teams operate to achieve successful outcomes. In this e-book, Medical Economics showcases recent coverage of important EHR topics to help you improve your efficiency and maximize the impact of technology on your practice. This coverage includes the results of our exclusive national physician survey providing usability ratings of the top EHR systems in five key areas, including Meaningful Use attestation, clinical support, technical support, impact on quality of care, and patient portals. This also features the top 50 EHR companies displayed alphabetically to offer a predictive metric for a company s longevity in the market on as well as a capabilities checklist to use when selecting (or changing) an EHR system. Other key EHR topics include ways to maximize revenue, data, documentation, and patient portal use. Go to modernmedicine.com/ EHRbestpractices for more practical tips and to access Medical Economics content related to the implementation and use of EHRs. inside 07 Top 50 EHRs: EHR Capability Checklist 10 Top 50 EHRs: Top 50 EHRs 13 Top 50 EHRs: Scorecard 22 EHR 2.0: 4 ways vendors are building better systems 26 EHRs: 5 ways to put data into action 30 How to optimize your patient portal 34 E-prescribing rates soar among physicians 35 E-prescribing is benefitting healthcare system, but barriers to adoption remain 37 Ways to optimize EHR documentation at your medical practice 41 Utilize your EHR system to boost practice revenue About this ebook The information contained in this e-book is an aggregation of published works from Medical Economics. It was created to offer physicians a useful guide as it relates to implementation of technology in their practice. For more insights on this and other topics, visit our Resource Center at: medicaleconomics.modernmedicine.com/ehrbestpractices. 2 Medical economics

You know the drill: faxes, forms, phone calls, web portals, and the long wait before you get the prescription approved. No more. Simplify the whole process with CompletEPA, a real-time, end-to-end electronic prior authorization solution that s integrated within your EHR. As the solution for a majority of health plans, only CompletEPA delivers approved prescriptions before your patient even leaves the office. Ask your EHR to get CompletEPA For more information, visit Surescripts.com/CompletEPA Prior Authorization without the Frustration Copyright 2014 by Surescripts, LLC. All rights reserved. Medical Economics 3

Unleashing the Potential of Healthcare. We believe healthcare will get better with improved information. As the nation s most comprehensive health information network, we integrate with existing software systems to connect providers, health plans, pharmacies and healthcare technology partners helping improve the efficiency and effectiveness of America s healthcare system. E-PRESCRIBING Copyright 4 Medical 2014 Economics by Surescripts, LLC. All rights reserved.

Surescripts services are accessible to you through your EHR vendor. Electronic Prior Authorization E-Prescribing of Controlled Substances Immunization Reporting Medication History

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e-book Digital publication EHR capability CHECKLIST Does your electronic health record (EHR) system have the functionality you need? Choosing an EHR vendor that provides the services your practice requires is a complicated endeavor, and purchasing the wrong system can cut into practice finances and hamper workflow for years. This EHR Capability Checklist was designed by Medical Economics editors to help physicians evaluate their current EHRs or shop for a new one. Is your system up to snuff? See the checklist below to find out. VENDOR SUPPORT AND TRAINING Offers on-site training Provides online resources for training purposes, such as tutorials, online chats and downloadable educational materials Ability to create customized templates that suit the needs of your practice Responds quickly to technical problems associated with the EHR system Provides guaranteed turnaround times for resolving technical issues Offers fl exible and after-hours technical and staff support Provides U.S.-based technical support call centers PATIENT PORTAL Offers a patient portal Allows patient to view: Lab results Plan-of-care summary X-ray reports Other diagnostic testing Medical economics 7

Consultant reports Educational materials Ability to communicate securely through the patient portal Enables patients to schedule and cancel appointments through the patient portal Enables patients to request prescription refills through the patient portal INTERFACES Provides the following system interfaces: Reference Hospital Imaging Practice management (PM) system Devices EKG Spirometry Holter monitor X-ray QUALITY CARE AND REPORTING Produces quality data for Meaningful Use Generates quality data for Physician Quality Reporting System Enables providers to identify patients who are not meeting clinical guidelines for chronic conditions Helps physicians improve quality metrics Ability to implement at least five clinical decision support tools (such as drug interaction checkers) POPULATION HEALTH MANAGEMENT Generates reports on subgroups of patients (for example: women over 50 who are due for mammograms.) Creates patient registries that track the preventative and chronic care services provided to patients Ability to provide patient-care alerts Capable of exchanging clinical summaries across the spectrum of care Generates tailored educational materials for patients Ultrasound Provides customized interfaces to meet your needs 8 Medical Economics

FINANCIAL SUPPORT TOOLS Offers a practice management system or interface Offers revenue cycle management services Ability to track financial performance within the practice management system Physician EHR satisfaction 63 % of physicians would not purchase the same EHR system if they had a chance to do it over again 26 % of physicians are very confident their EHR system will still be viable in five years 67 % of physicians are dissatisfied with EHR system functionality 35 % of physicians believe their EHR has improved the quality of patient care 31 % of primary care physicians believe their EHR system has been worth the effort, resources and costs. 38 % of physicians are doubtful or very doubtful their EHR will be viable in five years 69 % of physicians say their EHR system has not improved coordination of care with hospitals Source: 2014 EHR Survey; MPI Group/Medical Economics Medical Economics 9

e-book Digital publication Top 50 EHRs Medical Economics is unveiling this exclusive report on the top 50 electronic health record (EHR) vendors in an effort to help physicians make purchasing decisions. Companies are listed in alphabetical order. Vendor System Name Public or Private Company Annual Revenue EHR Annual Revenue Website 4Medica 4medica iehr Private $6,000,000 $2,000,000 www.4medica.com AdvancedMD (ADP) AdvancedMD EHR Public $12,000,000,000 www.advancedmd.com Advanced Data Systems Corp. MedicsDocAssistant EHR/EMR Private * www.adsc.com Allscripts Healthcare Solutions, Inc. Touchworks EHR, Allscripts Professional EHR Public $1,400,000,000 $870,000,000 www.allscripts.com Amazing Charts, LLC Amazing Charts Private ** www.amazingcharts.com Aprima Medical Software Aprima EHR Private ** www.aprima.com athenahealth athenaclinicals Public $595,000,000 www.athenahealth.com Benchmark Systems, Inc. Benchmark Clinical Private $10,000,000 $3,000,000 www.benchmark-systems.com Bizmatics, Inc. PrognoCIS EMR Private $6,000,000 $6,000,000 www.bizmaticsinc.com CareCloud Corp. CareCloud Charts Private $11,000,000 $11,000,000 www.carecloud.com Cerner Corp. PowerChart Ambulatory Public $2,900,000,000 www.cerner.com CompuGroup Medical, Inc. (CGM US) CGM CLINICAL, CGM webehr, CGM ENTERPRISE EHR Public $50,000,000 $40,000,000 www.cgmus.com CPSI CPSI Medical Practice EMR Public $200,860,000 www.cpsi.com 10 *Revenue estimates gathered from Hoover s financial reporting. **Revenue withheld at company s request Medical economics

Vendor System Name Public or Private Company Annual Revenue EHR Annual Revenue Website CureMD CureMD All-in-One EHR Private $91,800,000 $62,200,000 www.curemd.com Cyfluent Cyfluent Private $5,000,000 $2,000,000 www.cyfluent.com DocuTAP, Inc. DocuTAP Private ** www.docutap.com e-mds, Inc. Solution Series, Cloud Solutions Private ** www.e-mds.com eclinicalworks eclinicalworks Private $280,000,000 $252,000,000 www.eclinicalworks.com Endosoft (Utech Products, Inc.) EndoVault Private * www.endosoft.com Epic Systems Corp. EpicCare Ambulatory, EpicCare Inpatient Private $1,660,000,000 $1,660,000,000 www.epic.com GE Healthcare (GE Corp.) Centricity Practice Solution / Centricity EMR Public $146,000,000,000 www.gehealthcare.com Glenwood Systems, LLC GlaceEMR Private $7,500,000 $7,500,000 www.glenwoodsystems.com Greenway Health, LLC PrimeSUITE, Intergy, SuccessEHS Private $350,000,000 www.greenwayhealth.com HealthFusion, Inc. MediTouch Private $35,000,000 $35,000,000 www.healthfusion.com Integrated Systems Management, Inc. Omni EHR Private * www.omnimd.com ipatientcare, Inc. ipatientcare Private $39,000,000 $39,000,000 www.ipatientcare.com Kareo, Inc. Kareo EHR Private $48,000,000 $48,000,000 www.kareo.com MacPractice, Inc. McKesson Specialty Health (McKesson Corp.) MacPractice MD, MacPractice 20/20, MacPractice DC, MacPractice DDS iknowmed (SM) EHR, iknowmed (SM) Generation 2 Private $15,000,000 $15,000,000 www.macpractice.com Public $122,460,000,000 www.mckesson.com MD On-Line, Inc. (MDOL) MDOL EMR Private ** www.mdon-line.com MEDENT MEDENT Private $42,000,000 $30,000,000 www.medent.com Medical Informatics Engineering, Inc. WebChart EHR Private * www.mieweb.com MEDITECH MEDITECH Private $597,840,000 www.meditech.com Meditab Software, Inc. IMS Clinical Private $35,000,000 $20,000,000 www.meditab.com MicroFour, Inc. PracticeStudioX16 Private $13,650,000 $12,000,000 www.practicestudio.net Modernizing Medicine, Inc. Electronic Medical Assistant (EMA) Private $17,300,000 $17,300,000 www.modmed.com MTBC ChartsPro Public * www.mtbc.com Nextech Nextech Private ** www.nextech.com *Revenue estimates gathered from Hoover s financial reporting. **Revenue withheld at company s request Medical Economics 11

Vendor NextGen Healthcare Information Systems, LLC System Name Public or Private Company Annual Revenue EHR Annual Revenue Website NextGen Ambulatory EHR Public $444,700,000 $335,000,000 www.nextgen.com Optum, Inc. (UnitedHealth Group) Optum Physician EMR Public $37,000,000,000 www.optum.com Platinum Systems Specialists, Inc. PlatinumEMR Private * www.platinumemr.com Practice Fusion, Inc. Practice Fusion EHR Private * www.practicefusion.com Practice Velocity, LLC VelociDoc Private $24,500,400 $12,800,000 www.practicevelocity.com Praxis EMR (Infor-Med Medical Information Systems, Inc.) Prime Clinical Systems, Inc. Pulse Systems, Inc. (Cegedim Group) Praxis EMR v5 Private $38,400,000 $38,400,000 www.praxisemr.com Patient Chart Manager Private $10,000,000 www.primeclinical.com Pulse Complete EHR Public $1,200,000,000 $92,300,000 www.pulseinc.com Quest Diagnostics Care360 EHR Public $7,100,000,000 www.medplus.com RazorInsights, LLC ONE-Electronic Health Record Private $7,000,000 $7,000,000 www.razorinsights.com SOAPware, Inc. SOAPware, myhealthware Private $5,600,000 $5,600,000 www.soapware.com Viztek Opal-EHR, Exa Private $72,000,000 www.viztek.net Download Find the Top 50 list and other EHR reference materials at http:// *Revenue estimates gathered from Hoover s financial reporting. **Revenue withheld at company s request How we got our data This Medical Economics project started in spring 2014 and concluded on August 28, 2014. Here is how the editorial team approached gathering company data presented in this report: 1 Companies offering complete, ambulatory EHR systems were given the opportunity to report company data by filling out a Medical Economics survey. Editors evaluated companies based on survey responses and other criteria. 2 When available, editors obtained revenue for publicly traded companies from published annual reports. 3 Editors used revenue estimates from Hoover s financial reporting if vendors did not complete the survey and if other information, such as published annual reports, was not available. Hoover s estimates are denoted with an * in the revenue field. 4 If editors obtained a revenue range, the low end of the range was used. 5 Some survey participants provided Medical Economics with revenue data for our internal deliberations only. Those vendors are marked with ** in the revenue field. 6 The Top 50 is listed in alphabetical order. 7 Some companies provided annual EHR revenue while others did not. That field was left blank when not provided. 12 Medical Economics

EH R S C O R EC A R D e-book Digital publication SATISFACTION WITH EHR SYSTEMS GROWS AMONG PHYSICIANS Exclusive survey gathers physician usability ratings of the top EHR systems in five key areas by KEN TERRY Contributing editor Considering the dissatisfaction that many physicians have expressed about electronic health records (EHRs), you might think that most doctors hate these systems. But, according to an exclusive Medical Economics survey, 55% of physicians are fairly or very satisfied with their EHRs, and 54% believe they have helped improve the quality of care. Forty-five percent of respondents said that EHRs have had a positive financial impact on their practices. Most of that is probably related to the Meaningful Use incentives from the government, says Michelle Holmes, MBA, a Seattle-based principal with ECG Management Consultants. I don t think it s the norm for people to say the profitability of their practice is better after EHR implementation than before it, from a productivity and cost perspective. About 80% of Medical Economics respondents had EHRs, and only 11% of those said they were planning to replace their system within the next 12 months. On the other hand, only 55% said they would recommend their EHR to colleagues. The satisfaction of physicians with particular aspects of their EHRs varied a great deal, and the market leaders were not necessarily the most popular among their customers. Since the survey sample was skewed toward small and medium-sized private practices, this doesn t surprise Holmes. The physicians in these practices probably selected the cheap and free products from smaller vendors, she notes. They re not using a system that someone else selected on their behalf. Internist Edward Gold, MD, an experi- Medical economics 13

enced EHR user who practices in a 59-doctor group based in Emerson, New Jersey, says many physicians prefer the inexpensive EHRs because they re simple, and they re meant to be easy to use. But they don t accomplish all the things that need to be accomplished for Meaningful Use. They don t give you the reports you need for the medical home, the reports you need to belong to an ACO. They don t have the interoperability or the connectivity that s required. They ll do for keeping an office record, but they just EHR usability ratings The performance of an electronic health record (EHR) system can mean the difference between a thriving practice and a struggling one. These systems impact every aspect of medical care, from the care physicians provide to patients to the practice s ability to get paid for the work it does. For this exclusive EHR Scorecard, Medical Economics asked thousands of physicians to rate their systems, on a scale of 0 to 10, in the key areas that matter most to them. Demographic information on the survey respondents can be found on page 34. Quality of care The effect your EHR has on the quality of care your practice provides An EHR system can either enhance or hinder the care a physician provides to his or her patients. The promise of EHRs is that they will help physicians and the healthcare system provide high-value care, but that remains largely unfulfilled. Some systems are closer to this ideal than others. The vendors that focus on helping physicians navigate today s healthcare challenges will thrive. Rank System Base Score 1 SOAPware 24 8.0 2 MEDENT 67 7.2 3 Healthfusion 29 6.9 4 e-mds 156 6.5 5 Epic 986 6.3 6 Amazing Charts 114 6.3 7 Advanced MD 27 6.2 8 Practice Fusion 255 6.1 9 Modernizing Medicine 42 6.1 10 athenahealth 221 6.0 11 eclinicalworks 540 5.8 12 Aprima 48 5.7 13 Care360 (Quest) 54 5.6 14 McKesson [All systems} 105 5.2 15 GE 256 5.1 16 Greenway* 227 5.0 17 Vitera* 108 5.0 18 Nextech 23 4.9 19 Cerner 211 4.6 20 Allscripts [All systems] 552 4.5 *Greenway and Vitera merged in late 2013 to become Greenway Health. 14 Medical Economics

provide the basics. This coverage highlights five EHR usability areas important to physicians: Quality of care, Meaningful Use, patient portals, technical support and clinical support. (See EHR system scores on pages 25, 26, 28, 30 and 32.) Attestation tools Of the respondents who used EHRs, 78% had attested to Meaningful Use in the past year. Sixty-eight percent said the ability of their EHR to enable them to attest to meaningful use was good or excellent. Internist Kenneth Kubitschek, MD, a partner in North Carolina Internal Medicine in Asheville, North Carolina, and Gold both said their EHRs made it fairly easy to attest in Meaningful Use stage 1. But like most doctors, they re having trouble with some stage 2 requirements for reasons that have little to do with the quality of their EHRs. Their challenges include getting patients 30% of physicians rated their EHR system as excellent at making attesting to meaningful use easy to use patient portals and exchanging care summaries at transitions of care in an environment where interoperability remains limited. One area in which EHRs seem to have made progress is clinical decision support (CDS). Sixty-eight percent of our respondents had a positive opinion of their ability to use their EHR to implement at least five CDS support tools, which is required for Meaningful Use stage 2. Holmes notes that the CDS tools in current EHRs go well beyond pop-up alerts in electronic prescribers that warn doctors about drug interactions, wrong dosages, and so forth. CDS is built into the documentation templates of many EHRs, she points out. For example, there may be prompts regarding out-of-range information on vital signs. Some of the prompts regarding practice guidelines, such as initial medications suggested for a patient with newly diagnosed Meaningful Use Percentage achieving Meaningful Use The ability to attest to the federal government s Meaningful Use incentive program is the primary reason many physicians purchased an EHR. But some systems have tools that make attesting easier than others. Satisfaction with this function is key, especially for meeting the challenges of stage 2. Rank System Base MU% 1 Epic 986 87% 2 Allscripts [All systems] 552 87% 3 Nextech 23 87% 4 GE 256 85% 5 NextGen 399 83% 6 Cerner 211 83% 7 eclinicalworks 540 82% 8 athenahealth 221 82% 9 MEDENT 67 81% 10 Vitera* 108 79% 11 McKesson [All systems] 105 79% 12 MEDITECH 102 79% 13 Greenway* 227 76% 14 Care360 (Quest) 54 76% 15 e-mds 156 75% 16 Aprima 48 73% 17 Practice Fusion 255 68% 18 SOAPware 24 67% 19 Modernizing Medicine 42 60% 20 Healthfusion 29 60% *Greenway and Vitera merged in late 2013 to become Greenway Health. Medical Economics 15

diabetes, are quite helpful, Kubitschek says. But many care planning prompts, such as suggested recommendations to an overweight patient, are unnecessary, he adds. Peter Basch, MD, medical director for ambulatory health and health IT policy at MedStar Health in Washington, D.C., observes that EHRs certified for Meaningful Use must contain certain types of CDS tools. These include reminder alerts, he says. But he feels that vendors have much further to go in this direction. For one thing, alerts that are fired improperly can lead to alert fatigue. Also, he notes, smart features could be developed to suggest diagnostic tests for a particular problem and to find out whether similar tests had been performed earlier. Connecting with patients About six in ten respondents gave a good or excellent rating to the usability of their 49% Fewer than half of physicians said their EHR system is capable of enabling them to identify patients who are out of bounds on specific individual measures, such as an elevated A1C. patient portal and the ease of updating EHR data on the portal. This is important to many practices because of Meaningful Use stage 2. The government incentive program requires that eligible professionals provide 50% of patients with online access to their records. They must also ensure that 5% of their patients view, download or transmit their health information online. And they have to demonstrate that they can exchange secure messages with patients. The main barrier to achieving these goals is not the technology, Holmes notes. Most portals aren t difficult for the practice or the patient to use. The hurdle is getting people to use them. Aside from that, Kubitschek says, his patient portal works very well. When I do my labs and other stuff, the information Patient portal Usability of the patient portal from your EHR vendor A functional and intuitive patient portal is key to lessening the administrative burdens faced by physicians and improving communication between providers and patients. It leads to more efficient workflow and boosts practice productivity. Studies have shown that patients who use a portal to communicate with their doctor are healthier and more satisfied. Rank System Base Score 1 MEDENT 67 8.1 2 Epic 986 7.1 3 athenahealth 221 7.1 4 Practice Fusion 255 7.0 5 SOAPware 24 6.7 6 Healthfusion 29 6.6 7 Amazing Charts 114 6.5 8 Modernizing Medicine 42 6.3 9 eclinicalworks 540 6.2 10 Advanced MD 27 6.1 11 Nextech 23 5.8 12 Aprima 48 5.7 13 Greenway* 227 5.5 14 McKesson [All systems] 105 5.5 15 Vitera* 108 5.3 16 GE 256 5.1 17 Cerner 211 5.1 18 e-mds 156 5.0 19 Care360 (Quest) 54 4.9 20 NextGen 399 4.8 *Greenway and Vitera merged in late 2013 to become Greenway Health. 16 Medical Economics

uploads automatically as soon as I sign it. And the patients are getting it, because we re talking to them. It has their problems, allergies, medications, and immunizations. We get messages back and forth from the patients. I ve been pretty pleased with it. Another benefit, he adds, is that patient messages come right into an EHR inbox, and physicians can decide to whom those should be directed. He has his nurse triage the patient communications. He can then reply directly to a patient message or send it back to his nurse, and can choose whether to save it to the chart. Vendor customer service About 60% of the respondents rated the quality and amount of EHR training and the 53% of physicians say they do not use their EHR vendor for billing or revenue cycle management 70% of physician respondents who do not have an EHR system have no plans to purchase one. vendor s ability to solve technical problems as good or excellent. Around the same percentage gave a thumbs-up to the quality of the interface between their EHR and practice management system (PMS), if they had non-integrated systems. On the other hand, many respondents gave their vendors fair or poor scores for their ability to solve technical problems (30%), the level of support the practice received in configuring the EHR (29%), the quality and amount of training (28%), and the ability to customize their EHR (36%). Basch believes that increasing transparency and competition have induced vendors to offer packages of software, training and implementation that are better than they Technical support Vendor s ability to resolve technical problems with your EHR Is your vendor there when you need them? Glitches and system crashes can derail a physician s day and harm a practice s workflow, not to mention the aggravation of waiting on the phone instead of seeing patients. Technical support and training a vendor provides is key when shopping for an EHR system. Nothing leads to buyer s remorse faster than poor customer support. Rank System Base Score 1 MEDENT 67 8.3 2 Amazing Charts 114 7.7 3 SOAPware 24 7.5 4 Modernizing Medicine 42 7.4 5 Practice Fusion 255 6.8 6 Healthfusion 29 6.7 7 athenahealth 221 6.6 8 Care360 (Quest) 54 6.6 9 Nextech 23 6.5 10 Epic 986 6.4 11 Advanced MD 27 6.4 12 e-mds 156 6.3 13 Aprima 48 6.3 14 eclinicalworks 540 6.1 15 Vitera* 108 5.7 16 Greenway* 227 5.6 17 McKesson [All systems] 105 5.2 18 Cerner 211 4.9 19 GE 256 4.8 20 Allscripts [All systems] 552 4.7 *Greenway and Vitera merged in late 2013 to become Greenway Health. Medical Economics 17

were. Holmes, in contrast, speculates that many physicians rate their vendors highly because they don t know how much of the support work is being done by their organization s IT staff or by super-users in their own offices. Gold and Kubitschek both give their vendors fairly high marks for training and technical support. But Gold notes that training varies greatly among EHR suppliers. The basic problem that most doctors have with EHRs has to do with the inadequacy of training. The lower level EHR vendors will give you six hours of training online. The more training you get, the more it costs, and doctors don t like costs. Doctors never invest enough in training, he says. His own group he adds, is big enough to afford its own IT person, who trains new staff and provides ongoing training to the 30% Number of physicians who said they have had their EHR system for more than 5 years. doctors and staff members. It s never once and done, he points out. In a higher-end system, there are so many bells and whistles that people are unaware of that could make their lives a lot easier. It s a continuous process of educating people. Quality reporting Seventy-nine percent of EHR users said their systems could generate quality reports. That s about the same percentage of respondents who said they d attested to Meaningful Use, which requires quality measures. But these statistics obscure the difficulties that some users have in using their EHRs to report on quality measures, Gold says. In some systems, it s easy to generate reports, he notes. Others require the involvement of the vendor, which charges the physicians to do this. Moreover, if doctors and practice staff aren t specifically trained to produce reports, it might be very challenging for them. Gold himself finds it fairly simple, he adds, because his system provides a dashboard for this purpose. Clinical support Ability to implement at least five clinical decision support tools Most systems can provide alerts and other notifications to help physicians provide better care to their patients, especially those suffering from chronic conditions that require constant monitoring. Intuitive clinical decision support including alerts and reminders, clinical guidelines, documentation templates, and focused patient data reports can help doctors improve care and meet quality measures. Rank System Base Score 1 MEDENT 67 8.4 2 Amazing Charts 114 8.1 3 Healthfusion 29 8.0 4 athenahealth 221 7.7 5 Modernizing Medicine 42 7.6 6 Practice Fusion 255 7.5 7 Aprima 48 7.5 8 e-mds 156 7.4 9 Epic 986 7.3 10 Care360 (Quest) 54 7.2 11 Advanced MD 27 7.1 12 eclinicalworks 540 6.8 13 SOAPware 24 6.8 14 Vitera* 108 6.5 15 Greenway* 227 6.3 16 McKesson [All systems] 105 6.3 17 GE 256 5.7 18 NextGen 399 5.6 19 Allscripts [All systems] 552 5.5 20 Cerner 211 5.5 *Greenway and Vitera merged in late 2013 to become Greenway Health. 18 Medical Economics

survey respondents More than 7,400 primary care physicians and specialists took part in this exclusive Medical Economics survey, conducted by Readex Research. The charts below provide a snapshot of the survey pool s pertinent information, including practice description, size, and affiliation, and electronic health record (EHR) use and history. at a glance 22% 19% 17% 12% 11% 8% 8% 2% 1% 25% 32% 15% 11% 5% 3% 8% 61% 28% 5% 4% 3% Practice description N=7442 Family Medicine Pediatrics Internal Medicine/Other IM specialty OB/GYN Other Surgical specialty Multispecialty group Cardiology No answer Practice size N=7442 1 physician 2-5 physicians 6-10 physicians 11-25 physicians 26-50 physicians 51-100 physicians More than 100 physicians Physician employment N=7442 Privately held Owned by a hospital/health system Part of a government system Other Not currently employed EHR use Years with current EHR system N=5755 20% NO 80% YES 40% 30% N=7240 20% 10% Meaningful use attestation in last 12 months No answer 2% 20% 78% NO YES N=5790 Planning to replace current EHR system 11% YES 89% NO N=5701 <1 year 1-3 years 4-5 years >5 years Top 10 ambulatory EHR systems, by number of respondents Epic Allscripts 561 eclinicalworks 551 NextGen 405 Practice Fusion 261 GE 257 Greenway 230 athenahealth 222 Cerner 214 e-mds 158 1004 Medical economics 19

Fairly high numbers of respondents said their EHRs could generate clinical reports on subgroups of patients (63%), identify patients who were out of bounds on specific measures, such as diabetic patients with elevated A1c levels (49%), and send alerts to providers and care managers about patient care gaps (45%). Eighty-seven percent of EHR users said their systems could do at least one of these tasks. Do many physicians use this data and the related workflow features to improve care and manage population health? Basch doubts it. The business case for using health IT to improve quality, he says, is still lacking in most practices. For Kubitschek and his colleagues, however, the challenge is much more immediate. They re too busy attesting to Meaningful Use stage 2 and getting all their quality reports right to worry about using the data for quality improvement, he says. Usability Nearly two-thirds of respondents gave above-average scores to their EHRs on two markers for usability: ease of ordering tests and medications, and ease of moving between sections of EHRs. And 53% of respondents rated their vendor s ability to customize their EHRs as good or excellent. Regarding customization, Holmes believes that most physicians can t readily distinguish between what their own IT people or other staffers do and what their vendor does. But employed physicians have a more difficult time getting things changed in their EHR than do private practice doctors, she says, because of the former s need for organizational approval. So she thinks the usability scores reflect the amount of control that physicians have over their systems in smaller practices. That doesn t explain the popularity of cloud-based EHRs, which allow little customization. Holmes thinks that practices that choose those products see other advantages in them. Among other things, she says, they re generally simpler to implement, learn and navigate than are more complex client-server programs. Basch gives credit to EHR vendors for improving the usability of their products in some ways. For example, he notes, physicians can order a test or a prescription anywhere in the workflow in many systems, 54% More than half of physician respondents say their EHR has had a positive impact on the quality of care they provide. 11% Number of physicians who said they have had their EHR system for less than 1 year. 45% of physicians reported that the overall performance of their EHR system was average to poor. rather than having to be at a certain point in the process. Kubitschek, says that the usability of EHRs has vastly improved since he started using one in 1995. While the vendors haven t made much progress in the past three years because of their focus on Meaningful Use, he says, he s recently seen some innovations that have made his EHR more user-friendly. Practice management systems Because finances are the lifeblood of practices, the practice management system component of EHRs or the standalone PMS bolted to an EHR is vitally important. But just 61% of respondents gave good or excellent scores to the ability of their system to post electronic remittance advice EHR usability report Survey methodology The findings cited in this report are based on a survey conducted by Readex Research and sponsored by Medical Economics. Through the use of an online survey, the purpose of this research project was to better understand use and performance regarding ambulatory electronic health record (EHR) systems currently available to medical professionals. Data was collected via an online survey from June 10, 2014 to June 27, 2014. The survey was closed for tabulation with 7,442 responses. However, a majority of the study s results are based upon the 5,790 employed respondents who indicated their practice has an ambulatory EHR system. As with any research, the results should be interpreted with the potential of nonresponse bias in mind. It is unknown how those who responded to the survey may be different from those who did not respond. In general, the higher the response rate, the lower the probability of estimation errors due to nonresponse and thus, the more stable the results. The margin of error for percentages based on 5,790 responses is ±1.3 percentage points at the 95% confidence level. The margin of error for percentages based on smaller sample sizes will be larger. 20 Medical Economics

(ERA) correctly; 53% did the same for their system s ability to provide feedback on coding errors. I thought those numbers should be higher, Holmes says. If you have a PMS that can t post an ERA correctly, you have a problem. That s core functionality that s been there for years. Some practices are still clinging to old billing systems that are no longer supported by their vendors, she notes. In addition, a substantial portion of the practice universe isn t even using ERA yet, according to a recent report. Optimization The bulk of responses to questions about the respondents EHRs ranged from neutral to slightly positive. To Holmes, this indicates that much more is buried beneath the surface of the survey results. For example, she says, she d like to know how much IT support the respondents had available to them and how much of the EHR s functionality they re actually using. Basch takes a more optimistic view. Considering all of the difficulties doctors encounter in learning how to use an EHR and changing how they work, he says, I d expect people to feel neutral to slightly positive. The determining factor in how an individual physician or a group feels about an EHR assuming it has decent functionality is the degree to which the doctors have optimized their system so that it helps them become more efficient and deliver better care. Says Basch, If you take a less than optimal tool and try to optimize it, you can get better results. Medical Economics 21

e-book Digital publication EHR 2.0: 4 ways vendors are building better systems While vendors have focused most of their development efforts on meaningful use and ICD-10 readiness, innovations are on the way to improve system functionality for physicians by Ken Terry Contributing editor 22 Physicians continue to express dissatisfaction with the usability and the workflow features of electronic health records (EHRs), yet these information systems don t seem to improve. One reason, experts say, is that vendors have poured most of their research and development budgets into meeting the requirements for meaningful use (MU) and the International Classification of Diseases- 10th revision (ICD-10). They have only so much of a development budget, and anything that s required by government regulations might take away from something else, says Doug Thompson, MBA, senior research director for The Advisory Board Company, a healthcare consulting firm. The poor usability of ambulatory care EHRs also can be attributed to shifts in the marketplace, notes David Kibbe, MD, president and chief executive officer of DirectTrust, a trade association for secure messaging networks. During the past few years, he says, the big EHR vendors have increasingly focused on hospital systems at the expense of ambulatory EHRs, partly Medical Economics because the bulk of MU incentive payments have gone to hospitals. At the same time, he points out, more and more physicians have gone to work for hospitals, and the employed providers have become disenfranchised in terms of their choice of information technology. Their choices, particularly in primary care, count for very little in the decisions made by those big corporate entities with respect to EHRs. Thompson believes that EHR vendors have improved their product designs over time. But today s EHRs are more complicated because of their increased functionality, he adds, and can be difficult to customize. Small to medium-sized physician practices may not be equipped to deal with the technical aspects of these systems. They re probably stuck with EHRs that are not customized enough, that are not easy to use, and that they don t understand very well, he says. Despite all of this, however, some innovations are starting to enhance the usability of EHRs. These include refinements in natural language processing, advances in EHRs designed for mobile devices, the addition of

context to clinical decision support (CDS), and the spread of direct clinical messaging. Read on to find out how these developments could benefit you, either now or in the future. 1/ Natural language processing The biggest problem that physicians have with EHRs is the way that these applications force them to enter data. Encounter documentation with pointand-click templates can be excruciatingly slow and difficult. Physicians don t like to type, and many doctors also have trouble using speech recognition programs, Thompson points out. Even if they can overcome these barriers, free text does not create the structured data that is required for MU and quality improvement. The ideal scenario for doctors would be to speak to the computer and have it convert their speech into structured data that would automatically go into the proper fields in the EHR. That technology, known as natural language processing (NLP), has been under development for years. The speech recognition engines used in transcription have become fairly accurate, but the ability of computers to understand medical terms in the context of speech and categorize them is still fairly limited. Greenway Health, an ambulatory EHR vendor, is making use of NLP in its Prime Speech module, which it co-developed with M*Modal, a vendor of speech recognition software. Prime Speech allows physicians to dictate and place content into existing custom clinical templates, according to Greenway s website. But Jim Ingram, MD, chief medical officer of Greenway, admits that Prime Speech is not yet able to transform speech into discrete data automatically. Prime Speech can take information from the Greenway EHR s patient face sheet including medications, allergies, and problems and export it into the speech document that a doctor dictates into. The NLP application can slot the past medical history data into one of six categories that are part of the visit note. As the physician dictates, he can pull parts of the medical history into the appropriate sections as he goes along. Vital signs go into the physical exam section, for example, and the problem list would go into the assessment section, Ingram says. For now, Prime Speech cannot extract newly entered data from the note and export it back to the correct fields in the face sheet, but Ingram says that s where the technology is heading. In the future, Prime Speech will also assist evaluation and management coding and trigger clinical alerts. Other vendors, including Allscripts and eclinicalworks, have integrated aspects of NLP into their EHRs. But so far, none of these companies has had a breakthrough that would significantly improve EHR usability. 2/ Mobility Most physicians now use smartphones and/ or computer tablets at work, and they would like to be able to use their EHRs on these mobile devices. The leading vendors have accommodated them to some degree by allowing their applications to run on an ipad or a smartphone, says Kenneth Kleinberg, MD, managing director for health IT at The Advisory Board. But more progress has been made in ambulatory care than in acute care EHRs, and there s a significant difference between ipad-native EHRs and mobile versions based on EHRs designed for desktops and laptops. One problem with trying to use the desktop model of an EHR on a mobile device is that the latter s screen is smaller, so some information may be cut off, Kleinberg notes. In addition, if a clinician tries to use the pop-up virtual keyboard on an ipad, it can cover up essential information, including alerts. Allscripts, Epic, and Cerner along with a number of smaller EHR vendors have all created native apps for ipads, Kleinberg says. Allscripts approach is to pick the 20% of functions that physicians use 80% of the time and include that in its ipad-native Wand EHR, recognizing that they ll probably have to return to the desktop to complete their work. Allscripts Wand gives physicians the ability to review and add to documentation, prescribe electronically, and communicate with staff. Not all vendors with mobile-native EHRs have focused on the Apple ios. Some, like Meditech and Siemens, have used the HTML5 browser approach to format their EHRs to run on any platform, including ios, Android and Windows. But some parts of the EHR functionality can get lost with HTML5, Kleinberg says. Some physicians have told Kibbe that EHR vendors have improved their product designs over time. But today s EHRs are more complicated because of their increased functionality, and can be difficult to customize. Medical Economics 23

they prefer the touch screens on ipads to using a mouse to point and click on desktops or laptops. Kleinberg acknowledges that this can be an advantage, but points out that typing is still much more difficult on an ipad than on a desktop. That s why speech recognition is an important technology for mobile devices, he says. While NLP hasn t yet achieved its mobile use potential, Kleinberg believes it s moving in the right direction. When you talk to the device, it s navigating to the right template. Some systems can recognize the field you re talking about just from what you re saying. You can go between tabs using speech; you can do almost all of it using speech, Kleinburg says. Noting that cloud storage of data files is essential when using mobile devices, Kleinburg adds: I believe you can do everything you need to do on an ipad, especially the large ones they have now. 3/ Clinical decision support Ideally, EHR alerts and reminders can help prevent harm to patients or remind physicians to provide essential care. Other kinds of CDS built into the EHR s structure can help doctors follow evidence-based guidelines. The drawback of alerts and reminders the most visible form of CDS--is that they can pop up unnecessarily or erroneously. In most systems, they re at a very simple level, says Dean Sittig, Ph.D., a professor at the University of Texas Health Sciences Center in Houston. Most doctors would say they re overly simplistic and are often wrong. Frequently, alerts are based on insufficient information. For example, the program might tell the doctor that Valium should not be prescribed to the elderly, although the patient in question is not old. As a result of such mistakes, Sittig says, physicians ignore the vast majority of alerts in EHRs. They think they re almost all wrong, or that they don t matter, or that they don t apply. In some cases, he points out, the EHR alerts create confusion because they don t include the context of why a physician made a particular medical decision. For example, perhaps the physician is prescribing a small dose of Valium to an elderly patient to ease his or her anxiety before an MRI test. A lot of the decision support we give is of that type: It s true and it s right, but it doesn t Accredited providers Direct messaging Find an accreditted DirectTrust network service provider Axesson CareAccord Cerner Corp. Covisint Data Motion, Inc. digicert, Inc. EMR Direct Healthcare Information Xchange of New York, Inc. Infomedtrix, LLC Informatics Corp. of America Inpriva, Inc. Integrated Care Collaboration IOD, Inc. Candidates for accreditation Alere Accountable Care Solutions athenahealth Corepoint Health, LLC Cozeva (Applied Research Works, Inc.) DataMotion, Inc. eclinicalworks Glenwood Systems GlobalSign, Inc. Health Companion, Inc. HealtheConnections RHIO Healthunity Corp. imedicor Nitor Group Source: DirectTrust pertain to this patient, Sittig says. To get the decision support to pertain to the patient, you usually need more context about that patient. Intermountain Healthcare, based in Salt Lake City, Utah, has developed a contextsensitive alerting system over many years, Sittig notes. As a result, he says, Its physicians accept decision support more than 95% of the time. Intermountain is replacing its homegrown EHR with a system from Cerner, which plans to integrate Intermountain s context-sensitive alerts into its own EHR, he says. But most other vendors aren t moving in this direction because they haven t seen customer demand for it. Meanwhile, researchers are seeking MaxMD MedAllies Medicity Michiana Health Information Network MRO Corp. NextGen/Mirth New Uork ehealth Collaborative Optum Relay Health Rochester RHIO Secure Exchange Solutions Surescripts Truven Health Analytics Updox Orion Health Pulse Systems, Inc. Qsource Quest Diagnostics Safety Net Connect San Diego Regional Health Information Exchange Shifox, LLC Siemens Medical Solutions USA, Inc. Simplicity Health Systems Utah Health Information Network Vitalz Technology, LLC 24 Medical Economics

ways to improve alerts. A recent paper that Sittig co-authored proposes a system for improving CDS by using web-based monitoring tools and an interactive dashboard for evaluating alert and response appropriateness. To avoid alert fatigue, Thompson points out, some vendors have designed their systems to present information to doctors about medication safety and dosing at the point of prescribing. Only if a prescribing decision is truly dangerous would the flashing light go on, he says. 4/ Interoperability Despite billions of government dollars poured into EHR incentives and health information exchanges, a recent Health Affairs article notes, the amount of data exchanged among providers is still very modest. To jump-start these communications, which are vital to care coordination, the government joined with the private sector a few years ago to create the Direct secure messaging protocol. Direct is supposed to be embedded in all EHRs that have been certified for use in the second stage of the MU program. It can be used to meet the stage 2 requirement that providers exchange care summaries at transitions of care. The use of Direct is starting to grow and is expected to increase rapidly in 2015, Kibbe says. His own organization, DirectTrust, performs an important function in this field. By accrediting health information service providers (HISPs), which carry secure messages between physicians with Direct addresses, DirectTrust enables the HISPs to trust each other enough to exchange secure messages. As of the end of July, the two dozen HISPs in the DirectTrust community were serving 13,000 healthcare organizations and had provided over 400,000 Direct addresses, according to Kibbe. Direct messaging can increase the usefulness of EHRs by enabling physicians to attach documents, such as care summaries, notes, and lab results, to messages they exchange with their colleagues. Hospitals can also use Direct to send discharge summaries and notices of admission and discharge to doctors. From a workflow standpoint, having Direct embedded in their EHRs is a boon to physicians, because they don t have to leave To avoid alert fatigue, some vendors have designed their systems to present information to doctors about medication safety and dosing at the point of prescribing. the EHR to view or download information from other providers. But there are also disadvantages. For example, Direct can t be used to search for information across the community. Secondly, it s designed only for point-to-point exchanges. Also, the data in the attached documents can t flow into the structured fields of the receiving EHR. Greenway has found that to be a problem for ob/gyn customers, who want the EHR to consume data attached to Direct messages, and vice versa, notes Mark Janiszewski, the company s senior vice president of product management. To make this happen, he notes, Greenway has built limited interfaces for medications, problems and allergies for use with with EHRs from vendors such as Epic, Cerner, McKesson, Meditech, and CPSI. Works in progress While the innovations described above are all works in progress, they seem destined to benefit physicians in the long run. In the meantime, Thompson points out, there are some significant differences among EHRs, including ease of customization, whether they allow physicians to move easily among templates, and how many clicks are required to accomplish a particular task. If you re shopping for your first EHR or considering a switch, pay close attention to what these systems can actually do, and don t depend on demonstrations by experienced users. Try them out yourself and visit other practices to see how specific EHRs are being used. Meanwhile, keep your eye on the innovations that will eventually make EHRs more usable. They may be arriving sooner than you expect. Medical Economics 25

e-book Digital publication EHRs: 5 ways to put data into action Physicians share strategies to improve quality metrics, chronic care by Ken Terry Contributing editor 26 Medical Economics Physician frustration over the functionality of electronic health record (EHR) systems has been escalating. While the source of physician unhappiness stems from the belief that expensive technology should make their work life easier, the reality is that this technology requires greater physician involvement at a time when many practices struggle to maintain adequate patient volumes and remain financially solvent. The disquiet over the current state of technology was well documented in a recent Medical Economics survey of nearly 1,000 physicians in which 45% of responding physicians said patient care had grown worse since they implemented an EHR system. Nearly a quarter of internists said the quality of care was significantly worse. While the message came through loud and clear in this survey, what can we learn from the silent minority about using data in their EHRs including their Meaningful Use quality reports to improve the quality of care they deliver? Jennifer Brull, MD, a solo family practitioner (FP) in Plainville, Kansas, shares office space, staff and services with four other FPs, four midlevel practitioners, and a nurse midwife. When she and her colleagues first implemented an EHR in 2007, she screened only 43% of her eligible patients for colorectal cancer; in the next few years, with the help of EHR reminders, she raised that rate to 90%. She also used the EHR to increase her patients recommended mammography rate from 65% to 99%. Chronic care also benefited from her practices EHR use. In 2012, Brull and her colleagues were regularly testing only 14% of their patients with diabetes for microalbumin. After educating their staff in the process and turning on an alert in their EHR, they raised that number to 95% within nine months. In 2012, only 11% of their heart failure patients had received a recommended echocardiogram within the previous two years; by the end of 2013, the network had increased that to 68%. Most of the data you need to improve the quality of care is in your EHR, says Rosemarie Nelson, a Medical Group Management Association consultant based in Syracuse, New

York. But in some cases, the tools to make the data useful are not there, she notes. Even when those functions are present, she adds, clinicians don t necessarily use them. If you find EHR documentation a bit overwhelming and resent the time it takes away from patient care, you might view the idea of using your EHR for quality improvement as a non sequitur. But some studies show that EHRs also do improve patient care and safety. Moreover, we re entering a new era of valuebased reimbursement, in which part of your income will be based on your quality scores. So it s worth considering how your EHR can help you raise those scores. EHR Challenges EHRs were not originally designed for quality improvement, but rather for improving efficiency and documentation so that doctors could get a return on their investment. But with the advent of Meaningful Use, vendors had to rewrite their software to produce quality reports in order to get certified for Meaningful Use. At the same time, physicians started to pay more attention to quality improvement. The Breakaway Group, a health information technology consulting firm owned by Xerox, surveyed physician practices with EHRs in 2009 and found that fewer than 20% of them were trying to understand how EHRs affected quality of care. Today, partly because of Meaningful Use, people are being forced to answer some of those questions, says Heather Haugen, PhD, managing director of the Breakaway Group. EHR vendors are offering better tools for quality reporting than they did a few years ago, Nelson notes. But the quality of these tools varies considerably, and some of them must be purchased as add-ons, she says. The leading EHRs include health maintenance alerts that remind physicians about some of their patients preventive and chronic care gaps when they see them. In some systems, however, users have to build their own alerts, Nelson says. If an EHR includes prebuilt alerts, you may be able to customize or add to them. Brull says this is not a big chore in her EHR. She has customized about 25% of the health maintenance alerts most of them in less than five minutes each. Certified EHRs must be able to extract quality data for Meaningful Use. While the clinical quality measures are very limited, they can be used in quality improvement, Nelson says. In some EHRs, for example, you can get a list of diabetic patients with an HbA1c >8 by clicking on the percentage of patients in that category. Unfortunately, Brull says, That s where it stops in our EHR software. You can t click on the patient s name and go to their chart, which is the most actionable next step. The other problem with the reports in Brull s EHR, she says, is that they can t be customized. That is one reason why her group has acquired web-based registry software that interfaces with its EHR. This application, which also has population health management features, can generate a wide range of custom reports. The ability to customize reports is something the EHR vendors are working on, Haugen says. But it s definitely not there. What most practices do, if they want to get this information, is hire people who can write those custom reports. Of course, many practices can t afford to pay a technical expert to program these reports, so it doesn t get done, she adds. Registry functions Registries, which track the services provided to patients along with indicators of their health status and due dates for recommended care, are not yet being widely used in healthcare, Haugen says. But some vendors have begun to incorporate registry functions into their EHRs, according to Nelson. Several vendors, for example, offer the ability to query the database for a range of dates, she says. For example, the EHR could supply a list of patients with uncontrolled hypertension who haven t been seen in three months and don t have an appointment in the next three months. Brull s EHR can t do this, but her group can use the web-based dashboard of its outside registry for that purpose. If I have a patient with high blood pressure (BP) who fails to come see me for a prolonged period of time, they won t show up on my EHR report, but they will show up on my registry report as a patient with hypertension who has not had their BP checked in an interval of time, she says. Making the data actionable Seeking to capitalize on the new opportuni- 5 ways to put data into action 1. Use EHRs as reminders 2. Customize health maintenance alerts 3. Use registry functionality 4. Share results with the healthcare team 5. Maximize benefits of structured data Medical Economics 27

ties for value-based reimbursement, a growing number of healthcare organizations are using EHRs and other kinds of health IT applications to identify patients who have care gaps. But relatively few of them are able to ensure that those gaps are filled, Haugen says. In large part, that s because EHRs lack the functionality to make the data actionable. For example, even if the EHR has a built-in registry, it may not be able to upload a list of patients who need a specific service to an automated messaging system or send a message to those patients through the EHR s patient portal, Nelson says. Brull agrees. There s a registry processor function in her group s EHR that lets the practice email a list of patients who need services, she says. But even if the network could send such emails securely, she notes, it s not easy to construct the end-to-end process with the outside registry. All the pieces are there, but they re not click here and do this. You have to know what you re doing, she says. Instead, the group exports the registry report data to an Excel file that includes patient demographic information, including addresses and phone numbers. Since regular mail hasn t proved to be effective, the staff either calls patients or contacts them via the patient portal, but it s not an automated process, Brull notes. The large group approach In a large group practice the challenges are somewhat different. The EHR usually operates on a central server, and the quality reports are programmed by the organization s IT department. The organization may also have a mechanism for contacting patients who are not in compliance with their providers care plans. Robert Segal, MD, works for Scottsdale Healthcare in Scottsdale, Ariz. His ambulatory EHR is used by hundreds of physicians that are employed by the healthcare system. When the system decides that it wants the doctors to focus on a particular quality area, a report-writing team creates the requisite reports, and data on individual doctors performance is sent to them monthly. In the near future, Segal says, the organization will begin giving the physicians comparative quality reports. He welcomes those Measuring quality Is your EHR up to the task? Evaluating your current electronic health records (EHR) system on its ability to deliver the data you need is key to improving quality performance. Look for the following specific benefits after installation of your EHR system, and try to quantify them: increase in staff productivity; increase of practice revenue and profit; reduction in costs outright or controlled cost increases; improved clinical decision-making; enhanced documentation; improved patient care; and reduced medical errors. Source: Shahid Shah because they will show him where he stands in relation to his peers and how he can improve his quality scores. While some healthcare organizations use this approach, others don t even share the quality data with their doctors, Haugen says. She cites the example of a large hospital group that was collecting quality data for Meaningful Use but was not communicating it to the physicians. They told her, We d like to see the data but no one is showing it to us. Haugen comments, In some respects, small practices are doing this better because their ability to affect the process is sometimes much more immediate. Structured data is key Although doctors don t like to hear it, their ability to use their EHRs to improve quality depends on whether they enter key data into the system in structured form. If the data is not in codified fields, it doesn t show up in reports or health maintenance alerts. 28 Medical Economics

QuEstIons to ask your VEndoR Uncover your EHR s limitations Q: Does the system fl ag overdue health maintenance items? How are these fl ags displayed? Q: Can the EHR system automatically generate reminders for follow-up based on specifi ed criteria? Q: Does the EHR come with preconfi gured health maintenance alerts? Q: Will my practice be able to generate queries, such as identify all male diabetic patients, aged 50 to 65, with A1c hemoglobin levels above seven? Q: Can my practice confi gure health maintenance templates without vendor support? Q: If so, are there any limitations to the templates we can build? Q: Does the EHR have a built-in patient registry that can be used for quality measure reporting? Q: Is the registry standard or is there an extra fee for the feature? Q: Can I query the EHR to identify certain patients, such as those with particular conditions or who use certain medications? Q: Can I create ad-hoc reports or am I limited to reports provided off-the-shelf? Can reports be customized? Q: Does the system notify me of abnormal lab results when they re received and provide normal ranges? Q: Does the system give me a way to measure my performance on quality measures and compare it to that of my colleagues? Consequently, those reports and alerts may not be reliable. Haugen, a strong proponent of structured data entry, acknowledges that this is a sore point for doctors. But not all data has to be structured to improve quality, she says. What practices need to do is find a happy medium between what data must be structured and what can be unstructured, she notes. Vendors must also do their part to make it easier for physicians and their staffs to enter the data, she adds. Nelson suggests that practices work on improving clinical documentation if they want to improve quality. Also, she says, the physicians in a group should standardize their EHR templates and enter data the same way. If one doctor uses a template that suits him or her, but nobody else uses it, quality improvement will suffer. In the end, you ll get out of the EHR what you put into it. If big chunks of data are missing, you can t use the information to deliver better care. Also, remember that the EHR is only a tool; process improvement is up to you and your staff. We can track the quality of care with the EHR, but the EHR doesn t change the care we re providing, Haugen observes. So we have a big step to take beyond the EHR. Medical economics 29

e-book Digital publication How to optimize your patient portal Getting patients to use the EHR patient portal is a key part of meaningful use stage 2 by Andrea Downing Peck Contributing editor 30 If you are a physician looking to optimize the use of your practice s patient portal, you may be the most effective marketing tool and an important reason for the technology s success or failure to build practice efficiencies and patient loyalty. About 25% of physicians or their care teams last year communicated with patients using a portal, according to Manhattan Research s 2014 Taking the Pulse survey. That number is likely to go higher as Medicare-eligible providers attesting for meaningful use Stage 2 (MU2) use secure messaging to communicate relevant health information with patients. Launching a campaign to extol a portal s 24/7 convenience and timesaving services is essential for driving up patient adoption numbers, but providers ultimately wield the greatest influence when encouraging patients to register and use the technology. When Jose Polanco, MD, joined Blackstone Valley Community Health Care (BVCHC) in Pawtucket, Rhode Island, as medical director in 2012, physicians were beginning to promote the portal in the exam room, a formula that helped push portal registration from Medical Economics roughly 2,000 patients to today s total above 3,300. It makes a huge difference because people want to talk to their provider, Polanco says. If your physician tells you, You can email directly with me, it s very powerful. People will walk out [of the exam room] and do the registration. In addition to supplying providers with small portal registration information cards to give to patients, BVCHC trained a cross-section of staff members ( front desk, medical assistants and nurses) at each of its three clinics in the portal registration procedure and hired an engagement coordinator to do outreach and targeted enrollment for the portal. Minimizing portal pain Patient engagement strategist Jan Oldenburg, a senior manager for healthcare and consumer advisory service at Ernst &Young LLP, acknowledges that the portal has been a problem for many practices, particularly if the impact on workflow has not been considered from registration through ongoing use. Getting portal use up should be thought

of as a team sport in the office, Oldenburg says. It has to be embedded in the workflow and everybody in the office has a role in making this happen. I recommend putting in scripts for everyone from the person who does the registration to the person who rooms the patient, for the nurse, the doctor, phlebotomist. Everybody has a role in getting a patient registered and giving them permission to use the capabilities and reminding them this is another way to make the clinic accessible to them. Oldenburg says providers also should find ways to make a portal rollout fun for both patients and staff by marketing the portal at community health fairs, offering prizes to staff members who register the most patients or holding monthly prize drawings for patients who sign up. An awareness campaign also can include theme days such as Hawaiian Fridays when staff show patients how to surf their way to the portal. Stop thinking about the portal as drudgery, but as something cool and innovative, she says. Promote it as a part of how we do business. Zachary Landman, MD, senior researcher, Institute for Strategy and Competitiveness at Harvard Business School, says registering patients is only half the battle. In the beginning, a lot of physicians and people who designed portals were under the impression that if you build it, they will come, says Landman, former chief medical officer at DoctorBase. You can have initial registration levels pretty high, but getting people to log on, access and use the portals has turned out to be a more difficult concept. Landman offers a simple method for transforming patients into active users. It s quite easy, Landman says. As a clinician, you just have to use it. The number one way to engage your patients is to use the portal to engage your patients. Reach out to them. Encourage them to put more of their data into the portal so it becomes not something the patient checks one a year when they get a lob, but a dynamic process and a relationship building tool between not only the physician, whose time is constrained, but the entire care team. BVCHC s providers help drive traffic to the portal by sending patients pre-formulated email messages that alert them if a prescription refill has been sent to a pharmacy 4 tips to market your patient portal 1 Get 2 Simplify the entire staff involved Everyone in the practice should be involved in promoting the benefits of using the patient portal. The front office can display signs and posters, staff members can distribute brochures to patients, and providers can discuss the use of the portal during patient visits. registration Have a staff member assist patients with registering for the portal. If you can overcome the registration barrier, patients will be more likely to use the portal. 3 Engage A portal that provides mostly administrative functions, such as scheduling appointments and obtaining lab results, will be helpful but not as interesting to patients. Patients will be more likely to use a portal that is designed to address their personal needs. Portals that include interactive and personalized tools will be more engaging. 4 A Source: HealthIt.gov two-way street One of the best ways to convince patients to use the portal is to communicate with them through it. Communication should go both ways. If a patient sends the physician a secure message through the portal, reply using the portal function (using case-by-case discretion, of course). or a lab has returned normal. In addition, at the end of each office visit, they send a Patient Plan document to the patient s portal that includes a visit summary as well as goals and educational information. By sending something to the portal, we re making it more meaningful for the patient to visit their account, Polanco says. Until recently, however, BVCHC s Next- Gen portal was available only in English, effectively excluding the practice s large Spanish-speaking patient population from the site. We were going up against a very strong barrier for the first three to four years, says Medical Economics 31

It makes a huge difference because people want to talk to their provider. If your physician tells you, You can email directly with me, it s very powerful. Jose Polanco, MD, medical director, Blackstone Valley Community Health Care, Pawtucket, Rhode Island Nicole Gendron, BVCHC communications manager and project manager for portal implementation. Only in the last year has it become available in Spanish. We are hoping this will drive up our enrollment numbers. Embracing secure messaging Many physicians remain reluctant to adopt portal technology out of fear that secure messaging with patients will cause them to lose control over their personal time or expose them to increased liability. But Daniel Brown, MD, of Family Medicine Associates in South Attleboro, Massachusetts, has embraced email communication with his patients and has been rewarded for it. It ends up being one of those unpredictable factors that increase the bond between provider and patient by increasing the level of trust or comfort, he says. I especially love receiving comments that say, Wow! I can t believe how fast you got back to me. The portal is a very, very significant factor not only in my satisfaction as a provider but also the satisfaction of my patients. Brown, whose 12-provider private practice has registered 75% of its patients for the portal, responds to patient messages periodically during the evenings and weekends, a habit he believes ultimately makes his workweek more efficient and enjoyable. If I check five or six times over the course of a weekend and take care of 15 or 20 messages that may have come in, that makes Monday morning a lot easier, he explains. If some nights, I go back and see if anything has come in, it will make tomorrow morning a lot easier. Occasionally, a patient will send him a never-ending email, a problem Brown solves with a no-nonsense reply. 32 Medical Economics I tell patients upfront that if I get a long message from you, my response will be: I m your doc, not your pen pal. Too much here for this format. Let s have you come into the office, he says. Brown, who uses athenacommunicator, says the portal and related add-on services produce benefits that go beyond decreasing phone calls and reducing mailing costs. The portal helps increase my efficiency and productivity by helping to shape a patient s next visit or by not tying up a spot in office for someone who has a new problem, a higher reimbursed visit, rather than a quickie follow-up just to find out that cream worked and the rash is gone, he says. Salvatore S. Volpe, MD, a Staten Island, New York-based internist and Medical Economics editorial board member, suggests providers attend more Health Information Management Systems Society meetings so they can see firsthand the money-saving advantages today s rapidly improving portals offer. Volpe estimates his eclinicalworks portal saved him at least half a full-time employee by streamlining appointments and reducing calls to the office for medical refills and referral requests. He also praises use of a mobile app that enables patients to share their health information with any doctor with Internet access. While debate continues over charging patients for portal access, Volpe agrees with the providers who view the technology as a part of doing business and a product that can pay for itself. I decided I wasn t going to charge people for it, says Volpe. It introduced efficiencies into my office, which covered whatever additional cost there were to have a portal. MedicalEconomics. com

The portal helps increase my efficiency and productivity by helping to shape a patient s next visit. Daniel Brown, MD, Family Medicine Associates, South Attleboro, Massachusetts Financial considerations have stopped him from opening the portal s secure messaging feature to patients, however. Once Medicare starts reimbursing, I ll build it into my workflow, he says, But until it gets reimbursed, it is hard enough to do patient-centered medical home and not get reimbursed from CMS [Centers for Medicare and Medicaid Services]. To add this additional feature would be very hard. The future of the portal As portals continue to evolve, Ernst & Young s Oldenburg hopes physicians reframe their view of the technology and no longer see it as one more thing that is being thrown at them. It is something that can be transformative in the way they practice medicine and transformative for their relationships with patients and the loyalty they build, she says. But Joanne Rohde, chief executive officer of Axial Exchange in Raleigh, North Carolina, believes patients will not fully embrace portals until the technology becomes a gateway to self-care, not simply an alternative to phoning their doctor s office. Patients definitely want to get more involved in their own healthcare, but patient portals right now aren t necessarily the right mechanisms to do so, she says. Patient portals as mandated by MU2 are doing administrative tasks, such as appointments and refills. They aren t making sure you are managing your blood pressure. They are not making sure you understand your disease state. That s what the industry needs to move toward for self-care. Rohde is hopeful Apple s new Health app, a partnership with Epic and Mayo Clinic, may provide the kick-start healthcare needs. The key is getting both the patient and the physician to step on the treadmill, because we are in an Internet-enabled world and healthcare is the last industry not to be, she says. Medical Economics 33

e-book Digital publication E-prescribing rates soar among physicians ONC report shows 7 in 10 physicians are using EHRs for patient prescriptions by Alison Ritchie Contributing editor 34 Seventy percent of physicians now use electronic prescribing through their electronic health record, and in 2013, the number of prescriptions sent electronically topped 1 billion, according to the latest report from the Office of the National Coordinator for Health Information Technology (ONC). The report, which analyzed data from Surescripts, looked at the volume ofe-prescriptions from December 2008 to April 2014, after the Medicare Improvements for Patients and Providers Act (MIPPA), an e-prescribing incentive program, was passed. The report found a ten-fold increase in providers e-prescribing rates during that timeframe. Minnesota had the largest increase, with only 4% of its physicians e-prescribing in 2008 Medical Economics and 100% of physicians doing so in 2014. As of April, Indiana had a 95% e-prescribing rate, followed by Massachusetts at 94% and South Dakota at 90%. The report credits the jump in e-prescribing to the MIPPA. Before it s implementation, the rate among physicians was at 7% in December 2008. The number of pharmacies that accepted e-prescriptions also increased during that period, from 76% in 2008 to 96% in 2014. The global e-prescribing market is growing at a rapid pace. It s projected to balloon from $250.2 million to $887.8 million by 2019, according to a report released in June by Transparency Market Research.

e-book Digital publication community-based practices found that error rates dropped from 42.5 to 6.6 per 100 prescriptions one year after the adoption of e-prescribing. Greater efficiency: Though it takes about 20 seconds longer per patient to enter a prescription into a computer than to write it by hand, this time is offset by the time saved because of the fact that less clarification is needed for electronic prescriptions, the authors say. At the pharmacy, meanwhile, prescriptions received electronically produce less paperwork and fewer issues that need to be resolved compared with paper prescriptions. Cost savings: The authors cite a study by the clinical network Surescripts showing an estimated $140 billion to $240 billion in savings and improved health outcomes over 10 years, mainly due to better medication adherence and reduced ADEs. The Surescripts study also found a 10% increase in the number of e-prescriptions filled compared with written prescriptions. In addition, e-prescribing systems that use MDS can help doctors choose lower-cost al- E-prescribing is benefitting healthcare system, but barriers to adoption remain by Jeffrey Bendix Senior editor E-prescribing is bringing substantial benefits to the nation s healthcare system, but significant barriers remain to its more widespread adoption, a new research study concludes. The study, in the form of a systematic review, examined the findings of 47 articles looking at e-prescribing which the authors define as the computer-based electronic generation transmission, and filling of a prescription from a variety of clinical and financial perspectives. The results appear in an article titled Electronic Prescribing: Improving the Efficiency and Accuracy of Prescribing in the Ambulatory Care Setting in the Spring 2014 issue of Perspectives in Health Information Management. The benefits found in the review include: Improved patient safety: E-prescribing makes prescriptions more legible, decreases the time needed to prescribe and dispense medications, and reduces medication errors and adverse drug events (ADEs) due to the presence of medication decision support (MDS) systems. One study of 12 Medical Economics 35

ternatives to brand-name drugs can reduce prescription drug costs. The authors cite a 2005 study involving 19 physicians that found a 17.5% decrease in prescriptions for highcost drugs compared with the control group, leading to a savings of nearly $110,000 over 12 months. Barriers to the greater use of e-prescribing include: Implementation costs: New technology requires training and information technology support for installation and upkeep, the authors note. A practice must take these costs into account when deciding whether to implement an e-prescribing system and when choosing a stand-alone system or one that is integrated into an EHR system. Alert fatigue: Faced with numerous alerts each time they enter a prescription, many providers stop reading the alerts, with the result that they may ignore a potentially dangerous interaction. Privacy issues: Without effective firewalls and other safeguards, prescription data transmitted electronically may be breached, leading to HIPAA violations and fines. In addition, most information breaches actually occur as a result of employees actions, so continuous training on security is imperative and can incur additional costs, the authors write. 36 Medical Economics

e-book Digital publication Ways to optimize EHR documentation at your medical practice Voice recognition software, scribes allow physicians to focus on the patient, rather than the computer screen by Beth Thomas Hertz Electronic health record (EHR) systems are built to help physicians improve their practices. But EHRs may also come between a physician and a patient during an encounter. Many physicians believe they spend more time typing into a computer instead of looking their patients in the eye. The bottom line: EHRs require physicians to rethink their documentation strategies. When physicians are trying to decide what is best, Peter Basch, MD, chair of the American College of Physician s Medical Informatics Committee, advises them to look at their overall goals. The issue is not just typing. The issue is understanding where we are in the evolution of having a computer in the room with a patient, he says. Is there is value in having a third party in the room with the doctor and patient? That third party is information that helps us deliver better, safer and perhaps even less expensive healthcare. He compares the new paradigm to a pilot using a checklist prior to takeoff. A good pilot doesn t just make eye contact with the copilot or stare out the window. A good pilot also attends to other appropriate information for helping to better assure a safe flight, Basch says. The same is true in medical care. We quickly forget why the computer is there. It s not a punishment for not taking typing in eighth grade. The primary purpose is not the documentation. The primary purpose is, at least in my opinion, how we better interact with the information. Options are available to physicians looking for a way to improve their doucmentation strategies. They range from typing furiously, while potentially ignoring the patient, to using scribes, voice recognition technology, or even continuing to take notes by hand and entering them into the computer later. How EHR is used is key No matter what input method is used, physicians must prevent the computer from impeding communication with patients, Basch says. Triangulate the screen so that the doctor, patient, and family can see it and use it as a tool to improve education, safety, and outcomes, he suggests. Do not keep the Medical Economics 37

Documentation strategies Pros & Cons PROS ISSUE CONS No extra expenses or equipment required Typing May make it hard to focus on the patient, especially if you aren t a fast typist. Frees up more of physician s attention; allows instant review Allows physician to focus solely on patient; having a second perspective can improve accuracy No training or extra investment required Voice recognition Scribe Keeping Paper Additional cost of software, some learning involved; still need to review for accuracy Ongoing salary and benefits for employee; potential discomfort for patient in having an additional person in the room Hard to share with other providers; may hinder reimbursement process; illegible handwriting can lead to errors; may seem antiquated to younger patients back of your head to the patient the entire visit and shield the screen so the patient can t see what you are doing. That s like paper records, but worse. Jason M. Mitchell, MD, who directs the Center for Health IT at the American Academy of Family Physicians, suggests that one way to keep the physician focused more on the patient rather than the computer is to have patients and office staff enter key information before the physician comes in to visit with the patient. Also, having polished typing skills makes a huge difference, as does the use of keyboard shortcuts, auto text abbreviations, checkboxes, dropdowns, pick lists, templates, and appropriate history reuse from the longitudinal record, he adds. Is typing a real option? Among the various options for documentation, some physicians find that frantically typing during the visit works for them. It can slow a physician down, but it doesn t involve additional costs or staffing. I have seen examples of this approach working really well, Basch says. If you are a touch typist, a good approach is do the minimum. Pay close attention to making sure the right boxes are clicked, but have someplace in your EHR field in which you can type quick notes so that you have accurate, contemporaneous notes. You don t have to ask the patient to stop talking so you can type grammatically correct sentences such as Patients has had a sore throat since Tuesday. We certainly didn t do that on paper. We scribbled TUESsore throat. You don t have to do any more on the computer, Basch adds. Voice Recognition software However, Nick van Terheyden, MD, chief medical information officer for Nuance, whose Dragon Medical software is the most commonly used voice recognition technology in healthcare today, sees that technology as a much better option. Historically, physicians wrote their notes on paper. Starting in the 1970s, documenta- 38 Medical Economics

tion had to be legible in order for them to be paid. This gave rise to a large transcription industry, he says. Early voice recognition technology could create a first draft, but it had to be cleaned up by a medical editor. However, today s technology can create a highly accurate transcript that the physician can review in real time and share immediately with other providers if needed, he says. Most physicians can learn to use voice recognition very quickly, he says. The technology lets users specify the dialect with which they speak and their medical specialty, and creates a profile to assist them. Some physicians may find they need to adjust their style of dictation, though. Van Terheyden s brother is a physician who realized through using voice recognition that he wasn t as fluent as he thought he was when he dictated, and worked to improve how he presents information. He is now proud of his clinical notes, van Terheyden says. Such improved clinical notes offer a complete narrative of the patient s story. More intricate details from the visit that may have been missed in the past are captured. We all look at lab results and vital signs, but we are really interested in the details of how patients present, he says. Eighty percent of my diagnostic process comes from the patient history, about 15% from my examination, and about a 5% contribution from the investigations and tests that confirm or refute my findings. If you only capture information from drop-down lists and checked boxes, you lose some of the fine details, he adds. Speech preserves it. As a bonus, patients can review the dictated notes on the computer screen with the physician and correct any errors. Who has the most vested interest in the successful outcome of the interaction? The patient, he says. They can make a wonderful, positive contribution. Voice recognition is a time saver for many physicians, he says. One physician he knows works in several locations, one of which does not have speech recognition capabilities. This physician often works an extra hour or more a day to complete his documentation at that location. Van Terheyden notes that there are many pricing models for voice recognition technology, based on how many patients the provider sees and the activities he or she needs to document. Some EHR systems come with the technology built in, so physicians do not see it as a separate cost. For others, the software needs to be added. Most systems will work with piggybacked voice recognition software, although not all. Many primary care practices can save enough money from eliminating transcription to recoup the cost of the software and microphone in three to six months, he adds. Also, voice recognition turns dictation into actionable data tagged against a medical vocabulary, van Terheyden says. This gives providers real-time feedback, such as suggesting a diagnosis that might be indicated by the constellation of symptoms. It can also help ease the transition to the International Classification of Diseases 10th Revision (ICD-10) because it prompts the physician to enter details, such as laterality, up front. Basch notes that some physicians use voice recognition in a hybrid manner, using a minimal template with key boxes and using voice recognition to add a narrative that accurately reflects what the patient said. This is a very powerful thing, particularly for patients who have had bad experiences with other doctors, he says. Scribes Another documentation strategy is hiring scribes. Scribes can be highly accurate and serve as a backstop for catching physician errors. However, they have several disadvantages, namely their ongoing salary, which they likely will expect to increase each year. Also, having a third person in the exam room can make some patients reticent to discuss their condition in a frank manner. Basch recalls that when he was in training decades ago, the most efficient doctor he ever saw was an ear, nose, and throat specialist who used a scribe. The scribe would tell the doctor the key points from the last visit or remind him of things he wanted to recheck, while he examined the patient and offered comments aloud. Certainly that is a way to do it but since it is expensive, it is not for everybody, Basch says. If you hire the right person and they know medical terminology, it can be a time saver. But know that you are still signing the notes, so you still need to review them. Medical Economics 39

Mitchell says that the usefulness of scribes can depend on the physician s practice style. Significant benefit comes from a bidirectional interaction of the physician and the EHR. Data validation tools, data reuse mechanisms, and clinical decision support tools are all dependent on the provider directly interacting with the EHR. This is complicated by putting a scribe between the physician and the EHR, he says. Some systems (SOAPware, for example) are introducing the concept of virtual scribes as a part of the EHR itself. This keeps the physician interacting with the record and the patient and benefiting from the data management and decision support tools that EHRs have to offer, Mitchell adds. Still attached to paper? Despite the spread of EHRs, paper charts are still very much in use. Basch, who has been in practice for 33 years, says they appeal particularly to older physicians who feel unskilled in rapid typing or proper use of voice recognition. If this is an issue for you, don t struggle with it, he says. Work with colleagues, a physician champion, your organization, or a vendor to come up with alternate mechanisms for data entry in the room with a patient so you can focus on the things that you need to. See if you can get a tablet that supports handwriting recognition. Or even stick with paper. In contrast to what some say, paper doesn t kill. Paper usually cuts. Medical errors can kill. Using paper in the exam room and inputting your notes later is better than leaving medicine, he says. If you are a talented person, don t give up. Mobile platforms can provide a midpoint for some physicians. For example, ipads can accept dictation and allow interaction. A software program that Nuance makes, called Florence, helps physicians access information from complex medical records. Instead of navigating a menu tree to find lab results, they can just say, Show me the lab results. Mitchell agrees that physicians must use whatever tools are necessary to provide the best care to their patients. The wrong EHR badly implemented and poorly used by a physician can cause far more harm than effective use of a paper chart. However, the right EHR, well implemented and skillfully used by a physician is far better than a paper chart, he says. 40 Medical Economics

e-book Digital publication Utilize your EHR system to boost practice revenue Value-based incentives can help practices offset EHR costs and derive a return on investment by Ken Terry It s difficult for small practices to get a return on investment (ROI) from their electronic health record (EHR) systems, even if they receive government Meaningful Use payments, health information technology consultants say. Still, it s possible for practices to achieve ROI if they participate in alternative delivery models that help them garner value-based reimbursement. The two traditional sources of ROI are increased efficiency and higher charges, based on better documentation. Using an EHR to increase efficiency requires major changes in office processes, and the government has recently increased its scrutiny of certain documentation techniques that help practices justify higher charges. As a result, says Michelle Holmes, a principal with ECG Management Consultants in Seattle, Washington, not many small practices can achieve ROI on their EHRs in a fee-forservice world. The big Meaningful Use incentive dollars were in the early years, she notes. So at this point, the practices spend is greater than what they take in, unless they re doing something in addition to the EHR implementation. Nevertheless, Holmes and other experts say, it s possible for practices to achieve ROI if they participate in alternative delivery models that help them garner value-based reimbursement. These include accountable care organizations (ACOs) that participate in shared savings programs; Patient-centered Medical Homes, which many insurers incentivize; and pay-for-performance programs that pay quality bonuses. All of these models, to varying extents, require the use of EHRs. Therefore, Holmes notes, not having an EHR represents an opportunity cost that can be quantified and weighed against the cost of installing a system. Most practices are still not receiving much, if any, income from value-based reimbursement. But ACOs and medical homes are increasing, and some physicians are beginning to see the possibility of achieving ROI. Medical Economics 41

Nephrology group counts on ACO Simon Prince, MD, is part of a seven-doctor nephrology practice in Manhasset, New York. The physicians have attested to Meaningful Use for two consecutive years, but those payments covered only 20% to 25% of what they invested in their EHR, Prince says. While the EHR has made the practice more efficient in some ways, in other ways it has decreased efficiency and productivity, he says. For example, documentation of patient encounters takes him longer than it used to. On the other hand, improved documentation has led to fairer reimbursement, in his view. With these and other factors included in the analysis, he says, the ROI on his EHR is around a wash, at best. But the group s participation in an independent practice association that has turned into an ACO could change the picture in the long run, he says. The ACO, which Prince leads, includes 325 doctors in 100 practices. It participates in the Medicare Shared Savings Program (MSSP) and is one of 29 ACOs that qualified for bonuses in that program s first year. The ACO also holds shared-savings contracts with several private payers. To participate in the ACO, a practice must either have an EHR or plan to acquire one within 12 months. The EHR is necessary partly because the Centers for Medicare and Medicaid Services (CMS) factors the percentage of ACO members who have achieved Meaningful Use into its bonus calculations. Also, some of the quality measures in the MSSP require clinical data that s easier to collect with EHRs. Prince believes that once the MSSP bonuses start flowing, they will help him and his colleagues in the ACO achieve ROI on their EHRs. He s not sure those bonuses will be substantial, but he believes that value-based payments will continue to increase for practices that participate in the Medicare and healthplan shared savings programs. Meanwhile, he points out, the ACO has barely begun to take advantage of its EHRs. The 30 EHRs used by member practices cannot yet exchange information with each other; when they do, it will be much easier to coordinate care. Currently, he notes, the ACO s population health management software uses claims data, combined with clinical data that practices enter on a web portal and lab data feeds. Incentives pay for small practice s EHR Jeffrey Kagan, MD, of Newington, Connecticut, practices internal medicine with one other physician and a nurse practitioner (NP). The group s EHR cost about $120,000, including interest payments. Meaningful Use incentives will cover most of that. Learning the EHR slowed the doctors and the NP initially, but productivity has rebounded, and they see more patients now than they did before implementing the system. Moreover, Kagan notes, We re billing at higher levels than we did before. So even though the practice is paying about $5,000 a year for software maintenance and may have to buy some new computers, it has achieved ROI on its EHR, he says. Kagan, a Medical Economics editorial board member, expects further ROI from participation in an ACO and from pay-forperformance. The EHR allows his practice to pull quality data that it sends to the ACO. In turn, the ACO reports on the physicians performance to CMS Physicians Quality Reporting System (PQRS), which pays bonuses for reporting. In addition, when insurance companies ask Kagan to fill out quality improvement forms, he can use the EHR to complete them, which results in small additional payments. While Kagan is not yet getting pay-for-performance bonuses from the health plans, he says, I think that s coming. Other sources of ROI As Kagan s story shows, it s still possible to get ROI from a combination of meaningful use incentives, efficiency, and higher charges. But it s getting harder to pull off. Some people do get ROI, but it requires real change, observes Rosemarie Nelson, a Medical Group Management Association healthcare consultant in Syracuse, New York and Medical Economics editorial consultant. People want to keep what they do the same, so they try to retrofit the technology into their current processes. But in order to take advantage of what the technology offers, your processes must change. Nelson says she has seen practices that don t take advantage of their EHR s ability to track test orders against results to see if they came back. Instead, nurses print out the orders and put them in a tickler file. Nor do they use patient portals that enable patients to EHR return on investment According to a survey of 49 community practices in an EHR pilot program: $43,743 the amount the average physician is expected to lose over five years using an EHR 27 % number of practices that would have received a positive return on investment, according to results of the survey. Source: Health Affairs, March, 2013 42 Medical Economics

self-register and enter their chief complaint and family/social history before scheduled visits. Holmes agrees that process redesign is essential if practices want to increase efficiency. But because of the tight MU deadlines, she says, people aren t taking enough time to implement these systems in a way that might increase efficiency. The amount of additional revenue practices can realize by coding higher depends on whether they were undercoding before they got their EHRs, Holmes notes. But even if they could raise their charges by improving documentation, CMS is looking closely at physicians who copy parts of past notes into current notes or who document by exception. The threat of being accused of fraud has thrown a chill into physicians, she says. As a result, many are coding more conservatively. Other factors Another key factor in ROI is the 5-year cost of an EHR system. Vendors of web-based EHRs claim that their products are cheaper than site-based systems because they have a lower upfront cost. But Nelson says that the research she s seen shows that the differences in 5-year costs are insignificant. Holmes contends, however, that there is a difference in cost that depends on the size of the practice. Larger groups can get economies of scale by hosting their own EHR, but small practices can t. Therefore, the latter are probably better off with a cloud-based EHR, she says. Costlier EHRs have sophisticated features not found in modestly-priced systems, including business intelligence and advanced reporting features that can be useful in population health management. Holmes doesn t think that small practices need these features. That s one way to look at the ROI, she points out. How much are you paying for the stuff you re actually using? If you re paying $1 million for the EHR, but you re only using the features and functions you could have gotten in a simpler EHR for $250,000, you may have overpaid. Estimating a return on investment When constructing a business plan for the purchase or switch of an electronic health record (EHR) system, most practices need to consider four cost centers: hardware, software, Nelson sees the cost/benefit ratio in terms of how well a practice implements its EHR. A really good Amazing Charts implementation probably has a way better ratio than a poorly implemented NextGen, she says. Finally, don t forget about the practice management system that comes with most EHRs. If that doesn t work well, you re going to feel the pain in your bottom line. For a variety of reasons, including the challenge of maintaining an interface, it makes sense to buy an integrated EHR/practice management system, rather than separate systems, Nelson notes. And if you outsource your billing, you should hire a service that uses the practice management system that comes with your EHR, she adds. If you re not getting ROI on your EHR, don t despair; that EHR could be the ticket to future revenue streams. But to enjoy those added revenues, you ll have to start participating in the programs and alternative care delivery systems available to you. Also, don t worry if you and your colleagues can t yet use your EHRs to optimize your income from these new models. As Prince explains, We re succeeding despite the challenges that we have with getting any data out of our EHRs. We find that the ROI from that perspective is limited for now, but the potential is there. implementation and training, support and maintenance. ROI is calculated by: Gross revenues collected Direct costs of an EHR Indirect costs of operating EHR Financing costs associated with purchases = Net profit (or loss) Medical Economics 43

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