ACO Survey – Interoperability and Cost of HIT are “Burdens”

This article (link below) reports findings from a survey of 62 accountable care organizations (ACOs) reported by the eHealth Initiative and Premier, Inc. 90% reported that the cost of HIT and its return on investment had become “crippling concerns.”  Areas that were seen as underutilized or underserved included:

  • Patient engagement tools
  • Referral management tools
  • Telemedicine
  • Remote monitoring
  • Personal health records
  • Smartphone applications
  • Data interoperability
  • Data quality
  • Health information exchange strategies
  • Analytics
  • Patient reported data mining
  • Unstructured data mining
  • Revenue cycle management
  • Master Patient Index (MPI)
  • Risk management

Improvements were seen in outcomes, cost, efficiencies, quality of care, reductions in hospital admissions/readmissions and ED visits, although they were modest.

Commentary:  This article provides very useful information and identifies the need to remove barriers to access to information.  The majority of ACOs reported they are  “facing significant obstacles in integrating and blending data from disparate sources.”  At this time a lack of implemented standards and success with removing business disincentives towards interoperability are threatening to compromise the success of accountable care initiatives.  Patients may be the only stakeholders with the legal and political clout to successfully promote cost-effective reform in this space; but as of yet they are relatively unengaged.

Article Link: The Landscape of Accountable Care and Connected Health: Results from the 2014 National Survey of Accountable Care Organizations.

Patients as Medical Record Keepers


A number of concerns have been raised by the medical community about giving patients control of their own version of their medical record.   Patients may elect to redact certain information from their medical records that they may view as sensitive (e.g., mental health history, history of drug and/or alcohol use, sexually transmitted diseases, etc.).  This has the potential to compromise the clinical record and hence clinical care.  However, it is extremely common for patients to present to clinicians for evaluation without any medical records. At that point the history must be taken directly from the patient.  Patients may again elect not to share sensitive information with the provider during the process of providing a verbal history.This is not considered to be outside the realm of typical patient care

The majority of patients would not remove information from the records they are maintaining.  In contrast, they have the time and motivation to assemble the entire record of care across the entire healthcare ecosystem.  These compiled records can then be presented to a treating physician and are likely to be far superior to having no records whatsoever during a patient encounter.  The provider will know that the records have been maintained by the patient and will need to maintain awareness that the information provided may not be complete and accurate.  .

In summary, allowing patients to maintain and edit their own medical records is no worse than relying on patients to provide an accurate history during a patient encounter.  It also allows the patient to provide a highly complete clinical record to a treating physician.  Providers will need to maintain awareness that some patients may elect to modify information in the record,  However, the advantages of allowing patients to maintain their own records greatly outweighs the inherent disadvantages of having an incomplete or absent record.

The information in this post represents the opinions of Dr. Michael Stearns

AMA Focus On EHR Usability – Not Enough?

Physicians in general are not satisfied with their EHRs, citing problems related to loss of productivity, difficult to learn tools, and excessive data entry requirements.  The AMA recently announced a framework for EHR usability which is an important component of any effort to improve physician satisfaction.  However, there are several other considerations that would allow marked improvements in user satisfaction with EHRs that do not require modifications to existing systems. These include advanced user training, workflow optimization, and improving the business acumen of EHR users.

The AMA outlined eight key challenges providers face when using EHRs.

  1. Enhance physicians’ ability to provide high-quality patient care;
  2. Support team-based care;
  3. Promote care coordination;
  4. Offer product modularity and configurability;
  5. Reduce cognitive workload;
  6. Promote data liquidity;
  7. Facilitate digital and mobile patient engagement; and
  8. Expedite user input into product design and post-implementation feedback.

All of these represent important considerations that EHR software vendors in particular need to address during software design and software implementation.  Solutions to each of these challenges are discussed in detail in the article (link below).

However, they do not specifically address several areas of need and opportunity that have impacted the use of EHRs. Given competing priorities and the software development life-cycle, in general many of these changes will not reach users for a minimum of 12-18 months. A small but growing number of EHR users have managed to take full advantage of their current systems to create patient care and business environments that have resulted in:

  1. Marked improvements in patient care
  2. High levels of user satisfaction with their EHR systems
  3. Increase levels of compliance with documentation and coding requirements
  4. Significant increases in revenue, primarily tied to increases in patient volume and adherence to clinical guidelines.

How can this be achieved?

1. Gaining an advanced knowledge of the EHR system: Providers rarely have more than a limited understanding of their EHRs.  Financial pressures and limited EHR vendor implementation resources typically result in inadequate implementations. Providers and their staff tend to learn just enough to generate notes, orders, manage results, and submit claims.  They typically do not have a full understanding of the capability of their systems and how it can be customized for marked improvement in workflow proficiency. Practices that become “experts” in their EHR and practice management systems have much higher satisfaction rates than those who only understand its basic features. Seeing a doctor who only has basic knowledge of their EHR is akin to employing an accountant who barely knows how to use a spreadsheet.

2. Assessing office workflow: Dramatic gains in efficiency have been achieved by practices that analyze the role of each office staff member and how the EHR can be used to greatest advantage to protect the practice’s most valuable resource: physician time. This requires knowledge of how other similar practices have achieved optimal results and a comprehensive understanding of the EHR and practice management system’s capabilities.

3. Understanding the business rules of medicine: Providers in general have a fairly limited understanding of specific payer rules on reimbursement tied to documentation and coding.  EHRs generally have automated coding support that when used by someone with advanced coding knowledge can significantly improve the accuracy of coding.  Most providers using EHRs are not aware of data elements supported by evaluation and management (E/M) coding guidelines that are not captured or addressed by their EHR systems.  A example of this is the ability to recognize 3 chronic conditions and their statuses in the HPI, or the ability to recognize that manual review of an image has twice the value of reviewing a report for the same image when determining the level of complexity of medical decision making.  A full understanding of these business rules and many others allow providers to make informed decisions when determining the final E/M code.

The Solution:

A focus on usability, as proposed by the AMA, is an essential aspect of any effort to improve the use and value of EHRs.  In addition, providers, vendors and consultants need to focus on getting providers and their staffs to more fully embrace and understand the features of their EHR and PM systems.  The value of workflow optimization in any industry cannot be overemphasized.  EHRs offer features that allow for significant improvements in workflow and documentation efficiency that users have generally not used to their advantage. No one would challenge a provider earning increased revenue if it was tied to increases in patient volume.  Finally, EHRs are not only clinical tools but also business tools.  A full understanding of coding principles and how a specific EHR supports decision making tied to E/M and other types of coding is greatly empowering to physicians.

Link to AMA Framework Document: Improving Care: Priorities to Improve Electronic Health Record Usability

The information contained within this article, unless otherwise attributed, represent the opinions of its author Michael Stearns, MD, CPC, who serves as a health information technology and compliance consultant.

Please submit comments.  Dr. Michael Stearns can be reached at

EHRs and the ICD-10 Transition: Planning for 2015

This article (link below) was published by AHIMA and reprinted with permission by Physician’s Practice.  It details recommendations regarding how EHRs users and vendors should approach the transition from ICD-9-CM to ICD-10-CM.  EHR vendors that are transitioning to SNOMED CT before the October 1, 2015 deadline for using ICD-10-CM will be able to offer a relatively smooth transition.  In some cases EHR users maintain local ICD-9-CM codes (e.g., templates, pick lists for diseases, etc.).  These individuals will need to work with their EHR vendors to identify where in their EHRs locally maintained ICD-9-CM codes may reside, and the steps needed to update them to ICD-10-CM.

Article Link: EHRs and the ICD-10 Transition: Planning for 2015

Author of article (and this post): Michael Stearns, MD, CPC