Galen Healthcare Solutions: Allscripts Consultants Enterprise EHR

I recently had a nice chat with a colleague analyzing HIT industry trends for Kalorama Information. Kalorama does industry research for the medical and life sciences for many of the major news and consulting organizations. I got in touch with her specifically because of Kalorama’s analysis on EHRs in 2012 which was used by Bloomberg Government for their (very expensive) EHR industry analysis for provider and vendors. She found that in 2012 one of the most immediate challenges for providers was implementing EHR systems that meet meaningful use standards. She also found that vendors were having trouble with interoperability and usability.

Fast forward to 2013; a lot has changed. Epic has grown to dominate many markets. Allscripts has a new CEO and a few new toys to play with. eClinicalWorks has become a force to be reckoned with in the small practice space. However, the challenges the providers are facing have changed. My colleague and I talked for a while about various organizations we each have worked with and came to the same conclusion: providers are now having trouble with interoperability and conversions of data.

The majority of physician offices have implemented EHRs, but they must now communicate with other entities such as HIEs and ACOs. With the increase in mergers and acquisitions, we are also seeing an increased demand for conversions from one system to another. These problems involve a thorough understanding of the underlying data structure as well as a solid foundation in interoperability standards such as LOINC, HL7, SNOMED, and CDA. The vendors have the expertise to work on the problems for their products, but they are not enthusiastic about helping clients switch off their platform. Selling the EHR has been the primary goal for vendors in the past, not technical support that moves a client away from their product. Vendors are under the assumption that if they make switching off their product difficult, then clients will be less likely to undertake the conversion or integration with a product that is not part of the vendor’s family of products. While this is definitely true for disgruntled clients, it only makes it frustrating for clients who do not have a choice in the products they work with. This reality has led to some very important questions.

Where is an organization to go when their own vendor is not supporting their efforts? How do organizations extract meaningful data from such complicated or cloud based databases? How can we become self-sufficient in managing our data? How does an organization meet new institutional and government requirements? Galen can help clients with these challenges, but vendors need to help by making products that play nice with others.

At the end of our conversation my colleague and I simultaneously came to the same conclusion: “Organizations feel like their data is being held hostage!”

Tags: Clinical Conversion, Data Conversion, EHR, Healthcare IT, HIE, HL7, ICD-10, Integration, Interoperability, Meaningful Use

I am currently working with Clark & Daughtrey Medical Group to solve a unique problem. The group, which boasts national accreditation in many of its specialties, is looking to report on PCMH measures in innovative ways. So we started a conversation on how we could help them reach their PCMH goals. We discovered that their payers are reimbursing them for performing various clinical assessments. To do this, they have custom charge codes that are manually entered into the practice management system based on a medical coder’s review of each note. The medical billing staff spends hours every day sifting through these notes and entering the charges based on pre-configured flags in the note. With over 800 patient visits every day, this task is tedious and costs the practice a lot of money.

They asked us if there was a way that we could help them report on certain items in their notes. Unfortunately the note data is not discrete like medications and problems. It is actually a complex document stored in a format known as XML.While XML is a structured language, the document is first compressed then stored as one long string of text in the database. This means that if you wanted to search through the note in the database you would first have to decompress the note and then scan through the entire document for an identifier that is specific to that note. That is a nightmare for any type of reporting!

After talking with the staff at Clark & Daughtrey Medical Group we realized that this entire process could be automated! Using Note Form Reporting, I have developed a way to identify the appropriate check-boxes in the note and automatically submit the charges to the EHR. If the level of service charge has already been processed, then the charge is automatically submitted to the practice management system; if the encounter level charge has not been submitted then the provider will see it in the Allscripts Enterprise application just like any other charge waiting to be submitted. Clark & Daughtrey Medical Group will no longer have to waste time and money searching these notes for charges, the possibility of human error will be reduced, and the charges will now appear in both in the practice management system and the EHR.

Tags: Allscripts Enterprise EHR, Allscripts PM, Custom Reports, Customizations, EHR Implementation, EHR Unstructured Data Mining, Enterprise EHR, Integration, Meaningful Use, Reporting, Technical, V11 Structured Note

The era of electronic health records has arrived and opportunities for innovative uses of data are plentiful for providers and vendors alike. Fueled by financial incentives from the government as well as meaningful use requirements, organizations that best position their data to help providers deliver patient centered care will flourish. Physician organizations are also becoming larger through growth, acquisitions, and mergers. These growth milestones provide organizations opportunities to reflect on the capabilities of their current medical record system in order to decide if their current system will keep them competitive in the future. These are the three types of organizations that will be purchasing a new Electronic Health Record (EHR) system in 2013.

The New EHR Adopter

  Buying a new EHR is not cheap which may explain why many smaller physician practices have held out on the investment as long as they could. Only around 20% of providers are attesting to Meaningful Use in the US. However, government mandates and incentives are forcing providers to overcome their resistance to EHRs. While larger practices initially lead the charge into the digital record world, SK&A has shown that small physician practices are growing their EHR adoption rates faster than larger physician organizations over the past few years. According to KLAS, many of the smaller provider organizations are using cheaper vendors such as athenahealth, eClinicalWorks, and Practice Fusion which have been enjoying their recent growth.

While there are still some larger organizations that need to adopt an electronic medical record system, the majority of the New EHR Adopters over the next year will continue to be small provider organizations.

The Acquired Converter

While the smaller practices are still adopting EHRs for the first time, larger practices, which boast an adoption rate over 78%, are experiencing a different phenomenon. Rather than leading the pack in adoption rate growth, they have been increasingly switching vendors! One reason for this is due to consolidation that is occurring throughout the healthcare system. Federal incentives for the development of Accountable Care Organizations are driving larger physician groups and hospital systems to acquire the small practices in their local area. According to the American Family Practice Journal, the only non-government EHRs that are predominantly used by these large physician practices (>50 providers) are Allscripts Enterprise, EpicCare Ambulatory, Cerner Millenium Powerchart, and InteGreat EHR.

As acquisitions and mergers continue, organizations will have an increasing need to be able to both communicate clinical information between existing applications as well as convert data from one vendor’s EHR to another. While the messaging standards such as HL7 and CDA are easing the integration pain, conversions are becoming increasingly difficult for organizations. Many smaller vendors have data structures that are easy to understand, however they often do not store data discretely making conversions a nightmare. Larger vendors have the benefit of storing data in a more logical way, however the sheer volume of data combined with the lack of support during the conversion process makes transitioning between EHRs extremely difficult. While it is understandable for a vendor to dissuade groups from moving off their software, some providers are beginning to feel like their data is being held hostage!

The Disgruntled Replacer

The last purchaser archetype for 2013 is for the small, but growing minority of providers that are dissatisfied with their EHR system. The CDC reported that a vocal 15% of all providers reporting to them are dissatisfied with their EHR choice. Some of these providers chose a vendor based on price and have outgrown their current EHR’s capabilities, while others chose an EHR that was not a good fit for their organization. These providers often have specific needs in their organization and need extra support from the vendors in order to meet the incentive goals that drove them to purchase their EHR. They need to integrate with local Healthcare Information Exchanges, report on quality metrics, report on financial incentives, and make adjustments to the EHR to fit the way they practice medicine. Providers don’t need to know how the software works; they just need to know how to use it effectively. However, IT specialists know that the quality of the data in the EHR is only as good as the quality of the data put into it by providers. Without the proper workflow training and support from the vendors on how to make the EHR work for a provider, organizations will have a difficult time just using the EHR and never realize the benefits of electronic data management. However, according to the American Association of Family Practice Management, 56% of primary care providers are not satisfied with EHR vendor support and training. This may be why the percentage of EHR sales to physician organizations that already had some form of EHR rose from 30% in 2011 to 50% in 2012 and is showing no sign of slowing down.

A Look Ahead

KLAS recently reported that vendors such as athenahealth, eClinicalWorks, Epic, and Greenway Medical Technologies are gaining market share while the traditional ambulatory EHR vendors such as Allscripts, Cerner, GE, NextGen, and McKesson are struggling to continue the explosive growth they saw over the previous 10 years. While no one vendor is the best for every organization, it is clear that the struggling vendors need to focus on creating better products and supporting them for their customers. With Cerner and McKesson in the lead in revenue and Epic and Allscripts in lead with the most implementations in the ambulatory space, the big players have an opportunity to learn from their mistakes. However, the ambulatory market is still open for any vendor to improve the EHR data structures, design more user friendly interfaces, design products specifically for specialty practices, and utilize technologies from other tech sectors such as phone apps. EHR implementations will continue to be a significant investment for organizations and it will be exciting to see the improvements to EHRs in 2013.

Tags: Adoption, Allscripts, Business Intelligence, Data Conversion, EHR Implementation, Epic, Healthcare IT, HIE, Implamentation, Meaningful Use

As 2012 came to an end and we wrapped up another eventful year here at Galen Healthcare Solutions, I did what I like to do as holiday songs filled the office – write a blog on interesting articles I finally got the chance to catch up on. The theme for the past year was Meaningful Use, of course, and Conor Green, Vice President of Triple Tree, a consulting firm focusing on healthcare compliance, payment integrity, and provider-payer convergence among other things, wrote a great article called “Numbers Don’t Lie – The EHR Market Must Consolidate” in August 2012 and I think is worth looking at again.

From 2011 through May of 2012, 2400 hospitals and 110,000 eligible providers completed the attestation process and received 5.7 billion dollars in the form of incentive payments for demonstrating meaningful use of their electronic health record systems. This accounts for nearly 50% of the hospitals and 20% of providers nationally. Attestation, by definition, is the process in which practitioners verify that they have used EHR in a manner that is congruent with the incentive program’s criteria.  Green mentions in his article that there is a discrepancy between the CMS press release numbers and the data released by the data.gov database, but finds 77,000 attestations were initiated between 2011 and May of 2012.

Green has some great charts that display the information in a valuable light. Of the reported 405 separate EHR vendors (550 vendors are listed on CMS’s Certified Healthcare IT List), approximately 336 of them offer an ambulatory product. As Green astutely points out, this signifies that over 200 vendors are without one provider that has successfully attested and qualified for MU incentive payments.

Looking at the relatively large number of vendors, a concentration of users attesting is found within the top vendors. Within the inpatient setting this trend is even more obvious, as the top 6 vendors represent 75% of the attesting population. On the ambulatory side, of 336 vendors, the top 15 represent 75% of the providers population attesting. While not that surprising, that fact is somewhat concerning. What about the other 25% of the provider population that utilizes the other 95% of ambulatory vendors? One might infer this data implies that 95% of the vendors are offering a product that is not serving 25% of the provider population well going into the future. With that said, this significant portion of the provider population are arguably subject to a higher risk of having to adopt a new EHR system and/or undergo a conversion as the industry consolidates.

Within the ambulatory market, Epic (which does not market an ambulatory EHR product) has a considerable lead among the top vendors in that particular sector. What does this mean? That the likelihood of hospitals acquiring or having some controlling role within the ambulatory setting is increasing. Green references “Becker’s Hospital Review” for a snapshot of this trend. Although there are a multitude of possible factors that are contributing to this trend, in the end, it all boils down to money.  The cost of purchasing, implementing, and maintaining an EHR and the efficiencies created by utilizing existing infrastructures and staff competencies (or lack-thereof) increases the value of a hospital-clinic relationship in regards to hospital hosted ambulatory EHR systems.

Green points out an interesting question with his example of Athenahealth & their Athenaclinical user base.  The vendor claims that of their 6000+ providers, approximately 2050 of them have successfully attested to date.  This begs the questions, “Why?” and “What about the other 3-4 thousand users?” Be assured, there are a variety of underlying causes for this short fall, but with the larger client’s I have had the opportunity to work with, there is one glaringly obvious reason – staffing. Overcoming the sheer obstacle of the work effort required to complete an initiative like adopting any EHR and being MU compliant has effectively excluded a large number of these practices and providers from attestation.

The resources needed to build a system that accommodates every specialty, individual clinic sites and subsequent providers, is substantial and in many cases unworkable for these clients, without support from vendors and third party groups. Add the fact that a majority of large scale EHR rollouts take significant amounts of time (as they onboard new providers and sites, supply adequate training, go-live support, application & IT support), not to mention staying current with the continuous software updates and policy changes in attempt to conform to MU criterion and you can quickly see how large of an internal Human Resources effort is required. But, I digress.

Green brings us back on topic by pointing out that one of the goals of MU is to improve interoperability, specifically, “A new national infrastructure to support deployment & beneficial use of EHRs…” Having upward of 600 vendors that offer thousands of products does not seem like a great environment to foster the success of the incentive program’s goal. Instead, it is the product of a demand (stimulated or not) being met by suppliers (capable or not) that are trying to get a “slice of the pie” of the EHR industry.

As Green states in reference to the EHR vendor market, “it certainly seems ripe for consolidation…” and I would have to agree.  Taking into consideration the hospital-clinic alignment trend, payer-provider alignment changes, and the fact that the incentive monies are limited and are quickly expiring and the future appears clear. From a business perspective, all of these factors indicate a maturing market, affected by a high number of entrants, vendors, and products that will result in consumers’ becoming more price sensitive as incentive monies that might have been used to subsidize the cost of EHR implementation become scarcer. With all that said, the market forecast looks like consolidation of EHR vendors and a downward pressure on prices are inevitable. This indicates there may be more adoption and conversion in the foreseeable future as the “best” EHR vendors compete for market share.

Tags: Adoption, Data Conversion, EHR Acquisition, EHR Consolidation, EHR Conversion, EHR Implementation, EHR Market Share, EHR Vendor Consolidation, EHR Vendor Market Share, Meaningful Use, Meaningful Use Attestation

The HITECH Act of 2009 allotted 27 billion dollars to encourage the nation’s healthcare system to adopt electronic healthcare records. Dr. Farzad Mostashari, the national Coordinator for Health Information Technology, put it best when he said “… you don’t get paid for installing an electronic healthcare record, but you get it for the meaningful use for electronic healthcare records.” His point being that the government does not want providers to just have electronic healthcare records, but wants providers to use them to their fullest capability in order to provide better patient outcomes. During the first stage of Meaningful Use, the government created certain measures and objectives with required thresholds to ensure EHRs were being utilized. This past August, CMS released the final rule for Meaningful Use Stage 2 to further the utilization of EHRs.

The final rule for Eligible Providers requires them to meet 17 core measures, and 3 out of 6 menu objectives. Some of the initial core measures have been dropped to make room for new measures. Previous menu objectives have now been upgraded to the status of core measures, meaning they are no longer a choice and must be met. Across the board all measures have seen increased thresholds for Stage 2. An example would be during Meaningful Use Stage 1 the required threshold for an eligible provider using CPOE was set at 30%. The final rule for Meaningful Use stage 2 doubles that threshold to 60%. This is a significant increase that will require increased compliance from providers. There has also been an increase in the pool of Clinical Quality Measures (CQM) to choose from for providers. This should allow for providers to find CQM that are more specific to their practice. In addition to the increased number of choices available to providers, they are now responsible for reporting on more CQM. During Stage 1 providers were required to choose six CQM, Stage 2 will require the selection of 9 CQM.

Fortunately, due to the recommendations of providers and industry experts, CMS has opted to push back the attestation period for Stage 2 of Meaningful Use to 2014 to give the industry and providers more time to prepare. The Allscripts Meaningful Use Stage 2 release is slated for Q1 of 2013, leaving nearly a full year to implement the changes necessary to meet Meaningful Use Stage 2 requirements. This will allow ample time for providers and support staff to adapt their workflows for the increasing demands and complexities of Meaningful Use Stage 2. An additional consideration for your organization would be to use this extra time to upgrade to version 11.4 of Allsripts Enterprise EHR^TM which was released in September 2012. This would give providers a jumpstart on adopting the usage of ICD-10. Providers might find it easier to focus on the adoption of ICD-10 by itself, rather than trying to cope with learning ICD-10 while simultaneously meeting the new more involved requirements of Meaningful Use Stage 2.

As a result of the increased usage demanded by Meaningful Use Stage 2 EHRs will be utilized to their potential more than they ever have been before. When providers start to truly leverage this technology they will start to see improved results in patient outcomes. Although some might find adapting to this technology challenging, ultimately it will improve patient care.

Tags: Enterprise EHR, Meaningful Use