Archive for the ‘Primary Care Physicians’ Category

Surprise! State Pharmacy Registry is Underutilized

Tuesday, November 27th, 2012

This news item on NPR station caught my attention. North Carolina Attorney General is worried that the doctors and pharmacists are not using the state built controlled substance registry as much as they should. Further, DHHS has commissioned a study to understand the reasons for low adoptions. 

This medical registry was introduced to prevent people from abusing drugs. The news and discussion is about overdose. They are related, but not connected. 

Regardless, there is a simple answer. EHR and SureScripts database. With Meaningful Use guidelines, EHRs must support drug-drug, drug-allergy interactions. With e-prescriptions, most EHRs also perform dose checks and warn doctors about wrong dosage. SureScripts database connects doctors and pharmacists. Doctors can pull up all the medications a patient has been taking, regardless of who prescribed them. So, if the patient was prescribed Oxycontin or Amoxicillin in California, a doctor in Reidsville, NC can still look it up. Since the doctors are already using the EHR, they know this information in the context of their note writing. Then write a new e-prescription for the patient. 

The state registry, while good, requires doctors to log in to a different website. Then search for  the patient using a bunch of parameters. If they find the right patient, they may be able to tell the meds this patient was taking.

Pharmacists are connected to SureScripts, from where they are also able to access the medication history of the patient. There is no need for either the doctor or the pharmacist to connect to the registry and do extra work. 

There are 2 distinct issues here and they are being mixed in the news articles.

1. Drug overdose:

Doctors are performing this step using EHRs. So, patients should not be prescribed more than recommended dose. Pharmacists can additionally check doseage, but I don't know why they need to look into state built registry instead of pharmacy databases. This is a more serious issue that includes patient and care taker education. It cannot be solved by a state registry. 

2. Doctor shopping:

Unfortunately this is common. Patients will go to different doctors to be prescribed pain medications. Doctors using e-prescription have the medication history built-in. I know cases where doctors identified these patients using the EHR. Of course they refused more prescriptions for these patients.

EHRs currently don't track meds that are written on paper and paid in cash. This meds history is sometimes available only in the state registry. Doctors have asked for this to be included in the EHR. But the state application has no interfaces. EHRs or any other automated system cannot pull this data. 

Doctors and pharmacists are already overburdened. Having them log into one more disconnected system is asking for too much. The state registry needs to integrate with applications doctors are already using. State legislators need to talk to the customers (doctors and pharmacists) instead of adding one more study.



Basics about the HIPPA Privacy Rule

Monday, October 1st, 2012

In order to stay away from nasty trial lawyers and draining courtroom or legal cases or charges, all providers should know the basics of the HIPPA (Health Insurance Portability and Accountability Act) rule.

Covered Entities

HIPPA contains the Privacy Rule whose goal is to protect healthcare information. First it is important to understand who HIPPA applies towards –which are called “covered entities”..

  • Health Plans
  • Healthcare Providers (this includes both clinicians and organizations)
  • Healthcare Clearinghouses (process non-standard health info to standardized versions –common in billing claims)

Business associates are entities or individuals, other than the covered entities, that provide services on their behalf and may have access to protected health information either by use or disclosure. The covered entity will need to use a Business Associate Agreement in this case in order to comply with the Privacy Rule. But the next question is what is protected health information.

PHI (Protected Health Information)

health information that is individually identifiable health information is one, including demographic data, that relates to:

  • The provision of health care to the individual
  • The individual’s past, present or future physical or mental health or condition,
  • The past, present, or future payment for the provision of health care to the individual
  • Anything that can be reasonably used to identify the individual

Common examples include full name, address, birth date, Social Security Number. Even photos can be included as such information.

Penalties for non-compliance

These are classified into different degrees of offense.

1) Not more than $50,000, imprisoned greater than 1 year, or both;

(2) If done under false pretenses, fine shall not exceed $100,000, imprisoned not more than 5 years, or both

(3) If the intention is to sell, transfer, or use individually identifiable health information for commercial advantage, personal gain, or to maliciously harm another, cannot be fine more $250,000, imprisoned not more than 10 years, or both.

Tips to stay out of trouble

1) Abstain from talking about patients in hallways, elevators or where others not involved in care are there.

2) If using an electronic medical record, log off the software or the operating system when not using.

3) Don’t share PHI in emails, on voicemails or jot down on notes/stickies which can be picked up by others.

4) If an organization, make sure all new patients are given HIPPA paperwork, employees sign confidentiality agreements while being hired and 3rd parties you enter with sign Business Associate Agreements.

You can never prevent all bad situations, but with this knowledge and advice Dr. Jitesh Chawla hopes that be accused for violating of the Privacy Rule is something that will never to happen you.

By: Jitesh Chawla, MD

CMIO Patagonia Health

Tips for Review of Systems in Medical Billing

Monday, September 24th, 2012

Combining History of Present Illness (HPI)  and Review of Systems (ROS) is possible when doing medical billing. Many medical billers think this practice is breaking a rule or impossible. However, documenting an element once to account for HPI and ROS is acceptable medico-legally when done correctly.

CMS states that physicians absolutely do not need to document an element two times just so the person performing medical billing knows it is meant to be used both for review of systems and history of present illness. It is perfectly acceptable to use an element for both.

The only time an element cannot be used in duplication is when you attempt to use it in the same area. For example, the complaint of chest pain cannot be used in ROS for musculoskeletal systems and the cardiovascular system. It can be used only for one location in the medical billing.

A medical biller also cannot use a timing phrase such as "began a couple of days ago" to account for both the HPI duration and timing. Direct medical documentation must be used.

According to Dr. Jitesh Chawla, healthcare expert, the most important thing to accomplish in medical billing is to make the bill match the service that was actually given. When this occurs, payment is made quicker. Medical billing companies can assist medical practices with this task. Outsourcing your medical billing be beneficial for your practice, however, better yet is to use an electronic medical record (EMR) that has an integrated practice management (PM)/ Billing system that can send statements directly to the payer. This takes the worry off correctly coding and billing by manual means and physicians will see reimbursements much quicker! Please stay tuned for more articles on this subject and feel free to share your thoughts in the meantime.

E&M Coding and EHRs

Saturday, July 14th, 2012

Another interesting article Fear of EHRs being wrong, doctos code E&M manually.

The report found that 57% of Medicare physicians use an EHR, and 90% of them use their systems to document E&M services. But most physicians still assign those codes manually, which could mean they are undercoding services that could qualify for a higher pay rate.

The article does not clarify why the distrust exists. Though the following statement hints that the EHR may force upcoding? 

Fenton said physicians don’t have enough trust in EHR systems to use the features that assign codes. She said HHS and the Dept. of Justice need to do some kind of certification of the coding capabilities and get them to agree that if something was coded incorrectly and physicians can prove they didn’t alter the software, doctors won’t be held responsible.


If fraudulent upcoding is detected, HHS and the Justice Dept. do not go after the software company, they go after the physician, she said.

Regardless, the recommendation from AMA is to have EHRs be certified in coding standards, along with Meaningful Use. 

This raises a few questions

  1. The physicians coded E&M manually before EHRs came along ( or billing manager or billing service did that). Those skills still exist. So, if a physician does not trust the EHR, by all means they should code manually.
  2. EHR's E&M code is a suggestion. It is based on a pure calculation. It is possible the documentation supports lower or higher coding. Physician is ultimately responsible for choosing the correct code. 
  3. Some EHR + PM systems will actually analyze E&M codes for the physician and public Medicare data. A bell curve will let the physician know if the code entered is appropriate. For example, if too many level 4 visits have been performed, EHR may suggest coding at level 3. This is to avoid audits.
  4. EHRs actually help in upcoding. It is easy to mark the required levels of HPI, ROS and PE. 

A physician I know, intentionally codes all visits at level 3, inspite spending 20-30 minutes with the patient. He is very proud of the fact that he has never been audited. 

Other physicians routinely upcode with EHR help. 

Shouldn't AMA focus on the root cause? E&M coding is a game. CMS should put a better system in place that does not require complex calculations. CMS auditors should have a medical background that understand the visit and the work done. Auditors cannot simply count the number of elements in HPI to make a determination. 

Along with the rest of the reform, making billing process simpler will make physician's life so much simpler! 

Health Care Software Sucks? Users Bear Responsibility! 6 Ways to Make it Suck Less

Monday, June 4th, 2012

I largely agree with the complaint that Health IT is complex. HIT does not meet user needs and I think it is largely designed by engineers, for engineers. As an engineer, having designed and developed large enterprise apps, my conclusion was simple, engineers are not listening to their customers. 

To some extent that is true. Engineers and product managers apply a lot of assumptions when building software. 

In the consumer web, customers demand better looking, easy to use software. worked because it was simple and easy. Financial institutions took a while to get started, but got hints and are slowly revamping their interfaces. Web designers constantly redesign their UI, analyze user reactions and tweak designs. The intense competition and customers willing to switch for a better product drives a large portion of this trend.

While health care software is more like enterprise software and cannot be easily switched, but customers still have a choice. They can and should demand better. 

End-Users Bear Responsibility

We have reviewed several Requests for Proposals (RFPs) few large organizations. Some of them we have responded to, most we ignore. The RFPs are usually decision by committee. Their 600-1000 line items can be summarized as follows

1. Detailed list of requirements about allergies, meds, problem lists, vitals etc. Everything covered by Meaningful Use. For example drug-drug reaction alert must be displayed. 

2. Detailed requirements such as "Assessments should be a drop-down list", "Drop down of immunizations" etc. 

3. Every feature, each user has seen in every product they have used in the past. 

4. Interoperability, security, HIPAA etc. These are already covered by MU. If something is missing, think hard whether you really need it or is it a want. 

The result, only 3-5 vendors can meet the requirements. 

The missing part? No one talks about workflow. There is no mention about current workflow or requirement to do a workflow analysis. There is no requirement for the product to be flexible in defining workflow.  If the product has to meet the 600+ line item requirements you are going to get the following:

1. It is going to be customized for the practice. That means it is expensive and time-consuming to implement

2. Product is going to be hard to use, because features take priority over workflow

3. Users will hate the product

But purchasers cannot be blamed, because everybody's requirements were met and they bought IBM. Remember no one gets fired for buying IBM? :-) [We have a lot of respect for IBM. This is an old phrase Wikipedia reference]


What Should Users do Instead?

1. Product requirements have to be simplified.

Is the product MU certified? If it is, get rid of about 60-80% of line items in the requirements spreadsheet. 

2. Understand your own workflow(s).

Now is the time the to optimize these flows. Don't keep doing things just because they were done this way in the past. If you need help, ask the vendor to perform workflow analysis. For example, I see this RFPs. "Must generate form X". Why is the form X required? If the EHR prints form X and someone fills it out with a pen, what is the point of the EHR. Instead ask the vendor how form X can be incorporated into the EHR. Confer with your staff, how can this be made better with EHR?

I have seen organizations where the staff did not enter allergies in a coded format. Talking to the staff, entering allergies required several more clicks. They worked around it by putting allergies elsewhere in plain text. The EHR had the feature requested. Though users did not use it, because it did not fit in the workflow. 

3. Put workflow requirements into your RFP.

Can the EHR be customized to meet your workflow? Charles Webster, MD describes workflow issues very well in his blogs here. According to Charles, don't fall into the trap of Frozen Workflow. He provides great steps on how to evaluate workflow in the EHR and avoid the "Frozen Workflow"

4. Focus on usability, workflow and requirements for today.

Typically any organization uses 20-50% of the product capability. This is not unique to Health Care. So, take a hard look when one user brings up an unique requirement. Users typically ignore most alerts that pop-up, a syndrome called alert fatigue. So, why keep asking for them? If it is for the purpose to provide legal cover, perhaps there are other ways to address this. It could be less intrusive message using appropriate colors. A report for the user on how many drug-drug alerts were ignored. 

5. Be willing to sacrifice sacred cows

Understand what is the end goal of the exercise. Of course the big end-goal is always improving patient outcomes.  To achieve that. common goals are to be able to create certain reports and qualify for certifications like MU, PCMH etc. Are the requirements  contributing towards the goals? If they are not, may be that requirement should not exist. 

6. Review Meaningful Use Stage 2 Proposed Usability Guidelines

Get educated on usability. 

NIST has put out a proposal for EHR usability standards (Draft copy). These standards are about patient safety. Ask your vendor whether they meet any of of those standards. HIMSS also put together an excellent document on EHR usability. Review these to understand trends and recommendations by users. 

Though NIST and ONC don't know YOUR workflow. ONC's usability standards are focused on patient safety. A simplistic example is to display patient name when prescribing meds, to avoid errors. This is a common issue, you are prescribing meds on one tab, patient name is on a different tab. 


The goal of the organization should be to get a product that end-users like and use in a proper way. If the software does not help the users, you will have low compliance and hard time training the staff, which defeats the purpose. A side-effect is the software acquisition and mainteance cost is reduced, which is a win-win for the organization and the patients. 


Behavioral Health and Information Sharing via HIE

Wednesday, April 11th, 2012

Behavioral Health has been largely left out of Meaningful Use incentives. This has to be addressed by ONC and CMS, the National Council is taking a stand on the issue. In the meanwhile, as Health Information Exchange (HIE) is picking up momentum. States are implementing HIEs to connect physicians, hospitals and patients. 

HIEs must include behavioral health agencies and data. A recent study by Colorado Regional Health Information Organization found strong support to share behavior health data. A few highlights:

  • Over 88% of participants (providers, patients  and others) agreed that behavior data must be shared along with the physical part.
  • Participants wanted data sharing under emergency and regular care conditions. 
  • Participants want data to be shared amongst their mental health providers, primary care, specialists and hospitals. This is the role of HIE.
  • Substance abuse data sharing was more acceptable to providers as compared to patients. Some responses wanted patient to control access.

Participants were also asked about any concerns. Biggest concern over the data sharing were

  • Privacy
  • Inappropriate use
  • Lack of control over sharing data
  • Accuracy 

These are the same concerns that HIE participants have outside of behavior health. HIEs and the regulators are putting in significant thought and effort into protecting patient data. As HIEs get more popular and mature, I believe these issues will be less concerning.

Though, different state regulation will cause some roadblocks. For example, North Carolina has opt-out. Patient data is automatically available on the HIE unless the patient explicitly opts-out. What happens if a North Carolina patient travels to state with opt-in policy. Will this patient's record be automatically visible to the providers in that state? 

These questions have to be worked through. Overall there is a strong agreement to share patient health care data, both physical and mental. 


Eliminating Tests and Educating Patients The Hard Way

Wednesday, April 4th, 2012

This new release from nine medical societies caught my attention. We are all for lowering health costs after all. These societies have also put together a short list of things "Five Things Physicians and Patients Should Question"

Finally, someone telling the patient what test is must, nice to do or does not yield results. 

For example, American Academy of Allergy, Asthma & Immunology says:


Don’t perform unproven diagnostic tests, such as immunoglobulin G (IgG) testing or an indiscriminate battery of immunoglobulin E (IgE) tests, in the evaluation of allergy.

Appropriate diagnosis and treatment of allergies requires specific IgE testing (either skin or blood tests) based on the patient’s clinical history. 
The use of other tests or methods to diagnose allergies is unproven and can lead to inappropriate diagnosis and treatment. Appropriate diagnosis 
and treatment is both cost effective and essential for optimal patient care.
Does an average patient know what IgG is? Why can't the academy explain what this means and what to ask the doctor?
Another one

Don’t order sinus computed tomography (CT) or indiscriminately prescribe antibiotics for uncomplicated acute rhinosinusitis.

Viral infections cause the majority of acute rhinosinusitis and only 0.5 percent to 2 percent progress to bacterial infections. Most acute 
rhinosinusitis resolves without treatment in two weeks. Uncomplicated acute rhinosinusitis is generally diagnosed clinically and does not require 
a sinus CT scan or other imaging. Antibiotics are not recommended for patients with uncomplicated acute rhinosinusitis who have mild illness 
and assurance of follow-up. If a decision is made to treat, amoxicillin should be first-line antibiotic treatment for most acute rhinosinsutis. 
My 5 1/2 year old son is prescribed antibiotics (usually starts off with Augmentin ) every 3-4 months. Sometimes more often, so this worries me. My medical literacy skills are at least intermediate by AMA's definition. I still don't understand what should I look out for, when antibiotics are an overkill? Maybe the pediatrician understands what this means. 
I think this is a better decision making chart about Uncomplicated acute rhinosinusitis from Washington State Department of Health. It succinctly states the symptoms to watch for and the action to take. It still has unusual terms like "purulent nasal discharge" and 39oC, but easier to understand. 
Since this is aimed at the patients, would be nice to have the text say something like this:
If the patient has following symptoms
1. Runny nose
2. Itchy eyes
3. No fever or fever less than 100
Avoid medications of type X, instead go with medication Y. 
Make it simple, so patients understand and care about this. In the spirit of patient engagement, I think these societies need to make this easy to understand and implement.
People can agree or disagree with the points, but at least they understand what it is and the reasoning behind it. 


Patient Engagement At Work: Improving Body Weight Control

Tuesday, March 13th, 2012

This is an example of patient engagement working to directly impact outcomes. Duke Obesity Program in association with others, conducted this study with a control group. A group of  high-risk, socio economically disadvantaged group of obese patients were part of the control group that received usual care and behavioral intervention. (Abstract of the study here)

The intervention included tailored behavior change goals, self-monitoring, and skills training, available via a website or interactive voice response; 18 telephone counseling calls; primary care provider endorsement; 12 optional group support sessions; and links with community resources. This high level of patient engagement yielded significant results. At the end of 24 months, the intervention group's weight loss was 1.03Kg and BMI reduction of 0.38 as compared to the other group. Medical News has more details here

The authors claim results can be generalized to a larger population. 


Patient Engagement: What is it?

Sunday, March 4th, 2012

I have been a reading a lot about Patient Engagement, especially since HIMSS 2012 and MU announcements. Everyone and their dogs agree that patient engagement is important. So, I set out to find what is Patient Engagement and why is it any good? 

Here are a few definitions, descriptions available on the Internet. Some of them were presented at HIMSS 2012. 

  1. Patient engagement means putting the patient in the center. Forming a doctor-patient team to treat whatever is ailing the patient. NEJM Study
  2. Engaged patients are compliant, priortize self-help, proactive to maintain health, modest distrust of health professionals. Blog from Stephen Wilkins
  3. According to GallupThese patients are not just "satisfied" or "loyal," they are emotionally attached to the provider's brands or services. They are engaged.
  4. A Commonwealth Survey (from 11 countries) also discusses importance of Patient Engagement. Quote from this article 

Research has found that patients feel more engaged if they can pick up the telephone and call the doctor’s office for answers. 

There are several more definitions. In my opinion, the gist of patient engagement is

  1. Patient needs to be informed about what the assessment is and the detailed plan.
  2. Discuss this detailed plan and get an agreement from both the physician and the patient
  3. Patient needs to be proactive and ask questions
  4. Patient needs to follow the regimen that was agreed upon
  5. Any changes need to be followed up by both the patient and the physician.
  6. Physician or someone in the office should be available to discuss any question patient may have 

I think this paper by Center for Advancing Health nicely sums up an engagement pact between the patient and the provider. 

A number of surveys indicate patients want access to their health data. Most of them want it online. On the flip side, not many physicians want to supply this data to the patients. As one doctor told me, if I give them too much data, the patients will start calling me all the time and ask questions. They will want detailed answers over mundane issues. 


Paient portal surveys:

OpenNotes findings (published in the Annals of Internal Medicine)


ICD10 – How bad is it?

Friday, March 2nd, 2012

How bad can it get? Every one is talking about ICD 10. Some oppose it's introduction in Oct 2013, some want it today. 

When Squawk Box on CNBC talks about it, you know this is crazy. Watch this video at 6:38, Joe Kernen, says ICD 10, you know what it is, ICD 9 has 18,000 rules. Under Obama care, ICD 10 will hve 140,000 rules. Then he goes on to give the usual weird ICD 10 example, 9 separate rules if you are injured by a parrot! He rants speaks about it for a few more seconds. Larry Bossidy (former CEO of GE) clearly has no idea what is the topic and quickly switches the conversation. That was hillarious :)  

Now ICD 10 is also being used as a political tool! This is ridiculous when the decision is data driven. There talks about how high the conversion costs are, but hardly anyone talks about how practices can get more reimbusrsement with proper coding. 

As far as I can tell, ICD-10 was being planned way before Obama took office. HHS submitted this final rule in Jan 2009

Regardless, MGMA is strongly opposed to introducing ICD-10 in Oct 2013. They either want it postponed or want a phased introduction. 

Healthcare CIOs think delaying ICD 10 is not such a good idea. This Edifecs survey (done at HIMSS 2012) claims delay would be catastrophic

With 18 months to go, if the industry cannot be ready to implement this change, I think we are in serious trouble. We at least need to start a gradual phase in, instead of complete postponement. 

Legacy EHR vendors have had over 4 years to get their software updated. 

As a cloud based EHR, Patagonia Health is ready to move to ICD-10 today. The Health IT industry seriously needs to get moving quickly on issues like these and focus on more important issues about patient outcomes and reducing health costs for the country. 

A quick FAQ on ICD-10