Many states are seeing the HITECH money as an opportunity to aggressively 

 to improve healthcare through adoption of EHRs and health information exchanges. 

The four states discussed below have vastly different plans for health IT, from the aggressive to the sublime. 

 Since 2004, MA has become a national leader in implementing health IT. The most recent health IT bill, 

, which set the groundwork for further state-led health IT initiatives and large-scale health IT adoption among providers. This bill established the Massachusetts eHealth Collaborative, which is meant to oversee state health IT activities and promote adoption of health IT across the state, including the deployment of EHR systems networked through a statewide HIE. 

 questioned 18,282 physicians in order to test how much health IT uptake has been affected after four years of massive funding for health IT in MA. Of 519 who responded, roughly 36% use all “basic” EHR capabilities, which is about twice what is seen nationally. Unfortunately, only 5% of MA physicians “significantly use” advanced capabilities, which is just 1% higher than found nationally. In MA, 20% of 

 The uptake of EMR technology throughout Arizona has been credited to a 2005 executive order by then-Gov. Janet Napolitano, which required that all healthcare providers install EHRs by 2010. A 

 has stated that there is a marked increase in physicians who are canceling their EHR contracts and deinstalling their expensive c-EHR software systems. This is especially prevalent among smaller physician groups. Deinstallations and failed installations will be among the biggest factors that will keep a national HIE from becoming a reality. 

 that made it the first state to mandate a move toward EHRs. On May 11, 2009, 

 was proposed that would make it illegal to sell or otherwise distribute a non-CCHIT c-EMR in the state of NJ, applying penalties of up to $5,000 for multiple violations. 

It seems that its main sponsor had numerous financial ties with lobbying groups, including HIMSS, the “State Alliance for e-Health,” and the “Healthcare Information Management Society,” as documented in his 

. The idea of manipulating competition as a quid pro quo by making the sale of a non-c-EHR system illegal is bad policy. 

 was signed into law, mandating that all state-regulated health insurance payers (not just Medicare/Medicaid) need to provide monetary incentives to healthcare providers to adopt an EHR and use it in a “meaningful manner.” This law is meant to bolster the state’s efforts to create an HIE by October 2009. 

With this bill, the state is trying to cut off all physician choice concerning HIT by making a licensed practitioner subject to a host of grants/penalties depending on the degree of 

Several states are trying to aggressively 

 health IT /HIEs/EHRs, even though c-EHR systems have only been adopted by 17% of physicians, with only 4% of physicians “significantly using” them. 

Those legislators who are rushing HIT bills need to go slow, need to show due diligence in learning the nature and history of EHRs, and should consider the overall impact of health IT programs within the fiscal constraints of a recession. They should stay clear of improper lobbyist influence and associations with companies that may ultimately benefit from this health IT push. 

The growth of health IT will evolve slowly; it can’t be rushed with poorly written laws.

Alberto Borges, MD, is in private practice and is an associate clinical professor of medicine at the George Washington University in Washington, DC. Check out his website at 

Articles

Columns

Many states are seeing the HITECH money as an opportunity to aggressively promote health IT to improve healthcare through adoption of EHRs and health information exchanges.

States to Obama: Give Us that HITECH Grant Money!

Online Consultations and Using the Web to Improve Your Productivity: Mayo’s Experience with its First 2000 Online Consults in Family Medicine

 Participants will learn more about how to interpret the literature on e-medicine; review online consultation types, payments, and other online experiences; and formulate a plan for use of online consultation in their practices. 

Managing Your Diabetic Patient in the Office and the Hospital: An Evidenced-based Approach

 Attending physicians will learn how to apply current evidence in diagnosing patients with diabetes; treat patients in the outpatient setting with diabetes; and cite evidence in treating patients in the inpatient setting with diabetes. 

A Clinical Conversation: The Diagnosis and Treatment of Neuropathic Pain

 Dr. Brazzo will explain that chronic neuropathic pain is a disease resulting from injury to peripheral and CNS neurons (disease, drug, toxin, trauma, etc) and is not a symptom. He will also discuss how physicians should interpret the signs and symptoms that indicate a neuropathic origin as patients describe their pain, and also explain how to formulate an approach in performing an early and thorough history, exam, and diagnostic tests to accurately diagnose when neuropathic pain is present. 

A Physician’s Guide to Finding and Using Internet Medical Information

 Participants will learn to use Internet resources to support medical decision making in the course of daily clinical care; research and evaluate sources of good quality patient education information; and critique and evaluate new sources of electronic information as they become available.

 Looking for info on what to do in Boston while you’re in town for the AAFP Scientific Assembly? We’ve compiled a few links that will help you find the perfect restaurant, nightclub, or museum.

 to Boston Restaurants features dozens of no-holds-barred reviews and ratings for Boston metro area eateries. The lively discussion boards offer additional insight and opinions. 

Visit this site to find the most up-to-date and comprehensive information available on only the best restaurants out there. Organized by neighborhood, this site includes hundreds of dining options and their contact info, cuisine type, price range, links to OpenTable.com, photos and more. 

Visit The Institute of Contemporary Art/Boston to experience outstanding contemporary art in all media, including visual art exhibitions, music, film, videos, and performance. The ICA presents interpretative programs that provide context, develop appreciation, and add meaning to contemporary art and culture 

While you’re in Boston, visit the Museum of Fine Arts and check out “Viva Mexico! Edward Weston and His Contemporaries,” an exhibition of 35 rare works by Edward Weston taken during the pivotal years of 1923 through 1926, when Mexico was a powerful magnet for foreign artists and intellectuals drawn to its ideal climate, dramatic landscapes, and inexpensive cost of living. In the mid-1920s, a vibrant photography movement in Mexico City centered around Weston and his Italian-born lover, Tina Modotti, and, during the 1930s, on the Surrealist-inspired work of Mexican native Manuel Alvarez Bravo, as well as the American photographer and documentary filmmaker Paul Strand. The exhibit also features a select group of pictures by Weston’s contemporaries, including Modotti, Strand, and Bravo. 

Pulse

Here's some idea of what to expect at the AAFP Scientific Assembly.

Meeting Spot

Unexpected technology applications are transforming daily practice—everything from how you search for clinical information to how you share and store your data. As usual, Google is at the center of it all. But nowadays, the Web giant is about so much more than just search. Search is so 2007. Now, it’s all about the apps. 

“The Internet is fundamentally changing the way doctors practice medicine by enabling greater access to medical information, easier collaboration with patients and colleagues, and economic opportunities for entrepreneurs in Health IT,” says Roni Zeiger, product manager, Google Health. “Many Google services have powerful applications for a physician’s daily work. For example, Google Alerts and Google Reader are great ways for physicians to keep up to date with new research and news in their practice areas.” 

“We focus our coverage on apps that aren’t necessarily geared toward medicine but that, with a little bit of thought, could be well used in your dayto- day practice. “We are always looking for better ways to serve patients and physicians,” adds Zeiger. You might be surprised at what Google can help you achieve.

app to quickly and easily create customizable websites. How can you use this app? Let us count the ways: 

• Use it to create a website for your practice. 

• Organize a centralized online location for you and your project team (see an example at 

https://sites.google.com/a/altostrat.com/projecteggplant/Home

• Create an intranet for your office or practice to disseminate news and announcements, update schedules, post messages and reminders, track projects and paperwork, and more (see an example at 

http://sites.google.com/a/organic-city.com/intranet/Home

• Maintain communications and relationships with important vendors and other clients. 

• Publish patient education resources so you can guide the content that your patients see and read. 

The list is literally endless. To learn more about Google Sites and get started on your own projects, visit  

www.google.com/sites/help/intl/en/overview.html

Google says that it’s “a playground where our more adventurous users can play around with prototypes of some of our wild and crazy ideas and offer feedback directly to the engineers who developed them. Please note that Labs is the first phase in a lengthy product development process and none of this stuff is guaranteed to make it onto Google. com. While some of our crazy ideas might grow into the next Gmail or iGoogle, others might turn out to be, well, just plain crazy.” 

Before you get too carried away experimenting with the great apps and tools at Google Labs, a word of caution: The projects in Labs are intended to “showcase cool and wacky ideas but are not intended to be full-blown Google products. Labs experiments may be unavailable or be even removed without notice and you may not be able to access any of your data.” Google recommends that you not use sensitive information in a Labs experiment. 

Having said that, what will curious physicians currently find in Google Labs? 

Use this app to manage large collections (up to 100MB) of tabular data “in the cloud.” You can share the data with whomever you like. Apply filters, aggregate and visualize your data on maps and charts, merge from various tables, export, and hold discussions regarding the info based on row, column, or cell all, right in Fusion Tables. Learn more at http://tables.googlelabs.com/public/tour/tour1.html. 

Google Squared is an experimental tool that takes a category (like “hypertension treatments”) and creates a matrix, or “square” of information, automatically “fetching and organizing facts from across the Web.” You can modify your square by “removing rows and columns you don’t like—or by adding new rows and columns and having Google Squared attempt to fetch the relevant facts.” Google Squared “does the grunt work for you, making research fast and easy,” and is excellent for compiling educational supplements for your patients. 

Use this tool to manage your news and other data chronologically “on a zoomable, graphical timeline.” Set the timeline to weeks, months, years, or decades, or use a timeframe in a given query, and navigate through the information by dragging the timeline. Sample queries using “EMR,” “autism vaccine,” and “Kathleen Sebelius” quickly produced an enormous amount of well-organized and timely information. 

One of our favorite apps we’ve seen yet in Google Labs, Similar Images allows you to search for images using pictures rather than words. With the similar images feature, “most images have a link below them that lets you find other images like them. There’s no need for you to refine the text of your query. Your new results will be tailored based on whatever image you select.” So, if you’ve found a picture or graphic, but can’t figure out how to describe it, just click the similar images link to see “more like this.” Use it to find the perfect image for your next presentation, to illustrate patient education materials, and for a variety of other research purposes. 

Personalized health records are the future for portable, aggregated personal medical information. 

 already allows your patients to store and manage all of their health information in one central place. How does this benefit you? It allows them to keep you up to date with the latest changes to their health and information, eliminates the need for new patients to fill out the same paperwork over and over, prevents you from ordering redundant or already performed lab tests, and more. 

More companies and vendors are partnering with Google Health in order to integrate patients’ records and information into their systems. The list already includes Allscripts ePrescribe, Beth Israel Deaconess Medical Center, the Cleveland Clinic, CVS, Medco, Quest Diagnostics, and others. 

EHR vendors are starting to take notice, and many of them are working with Google to develop functionality that will enable them to interface, with Google Health, allowing physicians’ EHRs to populate key data into patients’ Google Health records. 

“Our hope is that as patients become more engaged in their healthcare and begin using the web to organize and manage their health information, more consumers will start asking their hospitals and doctors’ offices to use electronic medical records and integrate with consumer platforms like Google Health,” says Zeiger. 

Forget your local medical library and PubMed and use 

 to search for scholarly literature published in the form of peer-reviewed pieces, theses, books, and abstracts from any number of scholarly organizations, including professional societies, universities, and academic publishers. Search results are ranked by weight of the article’s full text, author(s), publication, and number of times it has been cited by other scholarly literature. 

Collaborating on an article with colleagues at multiple locations? Don’t run the risk of losing valuable work and time by e-mailing documents back and forth—get out of the past and into the cloud! 

 to upload text, spreadsheets, graphics, and more from your desktop. Control user access and edit your documents anytime, from anywhere. Share changes in real time in a secure virtual environment. Plus, “Google Docs has built-in capabilities to send an e-mail form, which could be a great way to gather feedback from patients,” says Zeiger. 

What’s new at Google Docs? How about more than 70 new “themes” and templates for creating forms and documents; new functionality that lets you view your projects with all formatting intact on your favorite mobile device; improved footnote capabilities; analytics tracking; custom colors and fonts; a brand new interface for creating slide presentations; and more. 

www.google.com/google-d-s/intl/en/tour1.html

Got a tip, trick, or suggestion for making Google Docs even better? Share it at 

www.google.com/support/forum/p/Google+Docs/label?lid=2040927159da752f&hl=en

Be sure to check out these additional noteworthy apps, both in released and “Google Labs” states. 

Get one phone number for your office, mobile, home, BlackBerry, hospital, or other phones; assign which one(s) ring(s) based on who’s calling you; get all voicemails transcribed; and call anyone in the US, all for free. 

This Google Labs offering allows physicians to host staff meetings, discussions with colleagues, and even potentially grand rounds with participants who can be anywhere that Internet access is available. Offering collaborative Q&A for group events, the app helps “keep things on track by allowing users to both suggest questions and vote on others’ questions.” 

Provide resources to patients in any of more than 40 languages through your website, translate patient pamphlets in any of these languages, or offer patients prescription information in their own language using this instant translator. “Take 2 with water” becomes “tomar 2 con el agua” in less than a second. 

Currently in beta stage, Knol enables anybody to share what they know with the world, specify the level of collaboration with the community, connect with other experts with similar interests, and see their great content become visible on popular search engines. 

Don’t want to sit through an entire presentation from the latest annual conference of your society of choice? Use the speech technology of this app, from Google Labs, to jump right to the good stuff based on your search terms. 

Enter a few items from any given set (eg, EMR, HITECH, technology) and this Google Labs app will provide a large or small—you decide&mdash;set of related items to be searched for using Google Search. 

Keep track of the latest news in your field or monitor the developing acetaminophen story with Google Alerts, sent right to the e-mail inbox of your choosing. The app allows users to search just about any topic, choose from various types of sources (eg. blogs, news, video), and determine how often the alerts arrive. 

Cover Story

Unexpected technology applications are transforming daily practice&mdash;everything from how you search for clinical information to how you share and store your data.

5 Ways Google Can Make You a Better Doctor

Since the HITECH Act was signed into law, physicians have had more questions than answers for the Office of the National Coordinator for Health Information Technology, the branch of the Department of Health and Human Services tasked, along with The Centers for Medicare & Medicaid, with overseeing the implementation of the incentive program outlined in the HITECH Act. The two biggest questions have been what constitutes a certified EHR under the rules of the program, and what exactly does “meaningful use” mean when it comes to qualifying for the incentive payments? 

A preliminary answer to the meaningful use question was released by the HIT Policy Committee on June 16. The 

 to the “meaningful use matrix” stated in part that the HIT Policy Committee recommends that:

“...the ultimate goal of meaningful use of an Electronic Health Record is to enable significant and measurable improvements in population health through a transformed health care delivery system. The ultimate vision is one in which all patients are fully engaged in their healthcare, providers have real-time access to all medical information and tools to help ensure the quality and safety of the care provided while also affording improved access and elimination of health care disparities. This “north star” must guide our key policy objectives, the advanced care processes needed to achieve them, and lastly, the specific use of information technology that will enable the desired outcomes, and our ability to monitor them...”

The Committee went on to note that “the recommended definition of meaningful use will depend on the healthcare setting in which it is employed. Thus, some features and capabilities will be recommended as required in an ambulatory setting before similar functions are expected to be widely used in the hospital. This reflects both the availability of the technology in these different settings as well as the potential impact of these features on the health of the population served. Although some recommended measures used to assess meaningful use in 2011 may apply to specific chronic diseases, the recommended 2011 objectives are meant to establish a foundation for effecting a more comprehensive set of health outcomes in the future. Many of the current proposed EHR-generated quality measures apply to primary care providers and are derived from NQF-endorsed measures. New measures under development, by NQF, and other recognized organizations will also address the work of specialists. The Workgroup anticipates that future recommended meaningful use objectives and measures will reflect emerging national priorities.” 

Finally the Committee pointed out that “in identifying potential criteria for meaningful use of an electronic health record, it became apparent that there are considerable gaps in EHR-generated measures available to monitor key desired policy outcomes, (eg, efficiency, patient safety, care coordination). While these measures will not be required for Medicare and Medicaid incentive payments until 2013, the Workgroup is seeking feedback on how to best frame these measures including measurement of key public health conditions, measuring health care efficiency, and measuring the avoidance of certain adverse events. These comments will be used to help revise the recommended measurement strategy to include more extensive and refined outcome measures for “meaningful use” in 2013 and beyond.” 

The first working definition of meaningful use is laid out in a meaningful use matrix, a document that matches specific “care goals” with health outcomes policy priorities and explains the year-to-year objectives for achieving these through the use of EHRs. The complete document can be accessed at 

The Office of the National Coordinator for Health Information Technology (ONC) is seeking comments, questions, and suggestions from physicians, vendors, payers, patients, and other healthcare stakeholders on the preliminary definition of “meaningful use.” The American Health Information Management Association was first to chime in, with recommendations offered on 

 to access a schedule of upcoming Health IT Policy Committee meetings, as well as transcripts and other materials from previous meetings. The public is invited to submit comments at the conclusion of each meeting.

 readers had a lot to say about all of this. And they’ve never had so many ways of making their voices heard before. Between Twitter tweets, comments on HCPLive.com, responses to our “Hot Topic” eDigests, e-mails to our editors, blog posts, and messages on discussion forums, 

 readers had ample opportunity to share their thoughts. We’ve compiled the best of the best ideas and opinions: 

“The bar has been set too high and the recommendations put forth will be virtually impossible to implement within the aggressive time schedule of the HITECH Act. Simply put, it appears that not enough attention was paid to the processes/workflow changes that are required as part of a successful HIT roll-out to meet these MU recommendations. For example, recommendations call for CPOE use in 2011. CPOE is extremely challenging to implement and the technology piece is actually a pretty small component of the overall implementation. The real challenge with CPOE is its direct impact on physician workflow and practices. Thus, CPOE requires significant forethought, process mapping, implementation and training. Getting all that done and to demonstrate meaningful CPOE use by 2011? Don’t bet on it.” 

“This is just the beginning of a long conversation. Today, the HIT Policy Committee met and highlighted some of the essential components that outlines this mysterious phrase, ‘meaningful use.’ We won’t see physicians meaningfully using an EHR overnight. This will happen in three stages (although many things will also be happening simultaneously): Data capture and sharing by 2011; advanced clinical processes by 2013; and improved outcomes by 2015.” 

— From HCPLive Network member Joseph Kim, MD, on his blog 

, a website dedicated to “unbiased independent EMR discussions”: 

“I am a tad confused. I have an EMR. Other physician groups have other brands of EMR. The hospital has no formal electronic record, but the nurses document electronically, and labs and rads are accessed through a portal (no CPOE or physician electronic charting). Who is supposed to create the features that will meet the “meaningful use” guidelines in this situation?” 

www.emrupdate.com/forums/p/20003/98803.aspx

I am sure that someone will come up in future with perfect system but at present it will cost at least $44,000 or more to implement the EHR/ EMR for every practice. The subsidy from government will help but in the end physicians will end up paying the difference. Hopefully this will be worthwhile in the longer run due to ease of finding charts in the practice and other EHR/EMR benefits. 

EMR no doubt will save doctors money in the long run, especially in reducing staff salary. I think in a busy practice, it takes at least one person who has to search, file, copy, reshelf, etc. paper charts. Some of the EMR systems, however, are so complex and costly that whatever the amount the government will ACTUALLY give out might not be enough. 

You do not install an EMR system on Monday and become “meaningful use” compliant by Tuesday; this is a social integration process that can take months to smoothly function! You MUST allow sufficient time and money for training. Plus, the number of QUALIFIED health IT personnel to help with hardware upgrades and software installation and coaches to help with the implementation is finite and they will be avalanched in 2010 & 2011 (read: more scarce and more expensive than today). 

Comments taken from “I’ll Get $44,000 to use an EHR? Where Do I Sign Up?” a recent column written by 

 Physician Editor-in-Chief Jonathan Bertman, MD. To respond to these commenters or Dr. Bertman, visit 

www.hcplive.com/mdnglive/articles/PC_use_an_EHR

The $787 Billion American Recovery and Reinvestment Act (ARRA) of 2009 (aka “the Stimulus Bill”) was signed into law on February 17, 2009. Included in this law is $19.2 billion which is intended to be used “to increase the use of electronic health records (EHR) by physicians and hospitals; this portion of the bill is called, the Health Information Technology for Economic and Clinical Health Act, or HITECH Act.” 

Technology for the Future of Health and Care

“ARRA authorizes the Centers for Medicare & Medicaid Services (CMS) to provide a reimbursement incentive for physician and hospital providers who are successful in becoming “meaningful users” of an electronic health record (EHR). These incentive payments begin in 2011 and gradually phase down. Starting in 2015, providers are expected to have adopted and be actively utilizing an EHR in compliance with the meaningful use definition or they will be subject to financial penalties under Medicare.”

Twitter is buzzing with physicians, CMIOs, HIT vendors, and other healthcare stakeholders commenting on the latest about the HITECH Act, meaningful use, CCHIT, the nuances of “certified,” and everything else related to the use of EHRs and other information technology in medical practice. Here’s just a sample. 

Ftvelasco - My take is that #CCHIT is addressing the structural component of ARRA. Other #HITPol criteria need to be satisfied to qualify for ARRA bonus 

Dirkstanley - confused by the uneven correlation between goals and objectives in the HIT Meaningful Use Matrix. 

BeckersASC - ASCs in Danger of Being Excluded from HITECH Incentive Funds 

EMR_Advocate - #CCHIT #HITpol All vendors will need to certify/re-certify for ARRA including 2008 CCHIT vendors (“delta process”) 

Pamorin - Numerous EHRs officially dead as won’t meet the min 2011 criteria w/out massive development. #hitpol (via @john_chilmark) 

Perryholz - “Meaningful use” turned out not so meaningful. Do over. 

Cascadia - “meaningful use” is ultimately linked to achieving measurable outcomes in patient engagement, care coordination, & population health 

CanadianEMR - Meaningful use in the US. Bar set too high with too little attention to process/ workflow changes. 

Feature Articles

What do physicians really think about the HITECH act, health IT stimulus incentives, and the government’s new role in their lives? Using the power of social media, we did a little research and asked MDNG readers to share their opinions, concerns, and advice.

Bonus or Bogus? Are federal funds for health IT a true stimulus, or merely a stopgap?

Sermo.com CEO Daniel Palestrant recently proclaimed that the AMA no longer speaks for US physicians, and that now is the time to “turn to entities like Sermo where physicians are establishing a new voice to collectively discuss the future of our profession.” We posted an 

 about this on HCPLive.com and also sent out a “Hot Topic” eDigest that asked readers to complete a survey and share their thoughts and opinions on the AMA, Sermo, and whether physicians’ interests and concerns are being adequately represented in the debate over healthcare reform. Several responses from readers are reprinted below. 

It is my opinion that the AMA does not effectively represent the interests of surgical specialists whose voices are often overwhelmed by the primary care predominance of the AMA’s membership. 

Physicians need someone to represent them and it is not the AMA, which is just another tool being used to manipulate the lives of American doctors. No one ever includes real practicing medical professionals in policy-making; rather they go to the AMA for the “pulse” of the medical community. Sites [like Sermo] that allow physicians to voice their opinions and truly poll their current feelings are relevant and more valid than the AMA. The system has taken away most of our rights and abilities to control our own destinies, and the AMA has been a willing participant from the beginning of the anti-doctor revolution. If Sermo is a viable forum and tool for physicians to fight back, we should and will support it. 

The AMA when first established represented the views of the doctors in the “trenches,” but now they have capitulated to our government and are not interested in the needs of practicing physicians. The AMA is only interested in self-advancement and maintaining its position. 

The AMA has a 162-year history of open dialogue in a democratically elected House of Delegates representing each state and specialty society. Reference committee sessions take place twice yearly where any member physician, not just delegates, can speak his or her mind about policy. Non-members may also petition to speak, and usually are granted the privilege! There is transparency in revenues and expenditures, including compensation of officers. Consensus creates policy; policy drives action. Sermo has a two-year history of dependency on the AMA. There is nothing democratic about its function; nothing transparent about its operation and financing. Just a naive entrepreneur who thinks he is the Phoenix about to arise from the ashes. 

—Dave Hannan, MD, president of the Medical Society of the State of New York 

I share the view that the AMA is too conservative and obstructionist to be useful, but I am not sure there is any organization that is able to take its place. I tell myself I should become more active in the AMA so as to have a chance to change its policies and politics, but, like most physicians, those good intentions get swept away by the demands of my everyday clinical and academic work. It is not enough for us to want change, we must find ways to make it happen--and I admit I have not been able to do this. 

The AMA makes money from its CPT and ICD-9 coding, which it reworks every few years. I have often wondered why the whole system cannot be replaced by... English? Why use numeric codes that must be translated into English? Why not just establish a unified English diagnostic lexicon? Because then it could not be licensed and would not require expensive training courses, meaning it would not be controlled by the AMA. Yes Sermo, no AMA! 

The discussion on Sermo was huge and interesting. It essentially involved two groups: the majority of Sermo users, who are conservative, some rabidly so, decrying the AMA for being too liberal and giving away the store, and the rest of us, decrying the AMA as too conservative and obstructionist on healthcare reform. The conservatives urged membership in the American Association of Physicians and Surgeons, a fringe group in my mind, but perhaps it will become the new home of some of the AMA’s disaffected conservatives. Liberals urged joining Doctors for America, Physicians for a National Health Plan, or the American College of Physicians (I’m in all three). The bottom line is that the AMA counts less than 20% of physicians as members. Older conservatives think it’s because they’ve gone soft and liberal. I think it is very clearly the opposite: Older, whiter, more conservative and more highly paid procedure-based specialists hold too much sway and have alienated the progressives, particularly in primary care specialties such as family practice, internal medicine, and pediatrics. 

Do you agree with Sermo CEO Daniel Palestrant’s claim that the AMA no longer speaks for the majority of US physicians and does a poor job of representing the interests of physicians? 

Sermo.com CEO Daniel Palestrant recently proclaimed that the AMA no longer speaks for US physicians, and that now is the time to “turn to entities like Sermo where physicians are establishing a new voice to collectively discuss the future of our profession.”

Hot Topic: The AMA vs. Sermo

You may have seen advertisements, or may already have been contacted by people who’ve promised to help you figure it all out so you can get your share of the stimulus money. Be wary. The truth is that the Obama administration is still defining many essential elements of the Health Information Technology for Economic and Clinical Health Act (HITECH), and full details about the exact reimbursement process will not be known until the fourth quarter of this year, at the earliest. 

Nonetheless, there is a growing field of people who call themselves “EHR consultants.” They promise to advise you on which system to purchase for your needs, help set up and integrate the necessary hardware and software, and perhaps even troubleshoot any on-going problems you may have. Sounds tempting, right? 

Let me stress that many EHR consultants are legitimate and can provide valuable services at a reasonable price. But there are some pitfalls to avoid. First, let’s define the difference between a consultant and a reseller. A consultant should be completely independent and have no relationship, financial or otherwise, with the vendors they recommend or refer to you. Conversely, a reseller receives payments from an EHR vendor for providing leads or getting a practice to purchase that specific EHR. An ethical consultant (ie, a reseller) will let you know upfront that they have a fiduciary relationship with one or more vendors, and then you can make an informed decision on the advice they provide. Many consultants and EHR/technology “experts,” however, quietly arrange kick-backs with various EHR vendors and fail to disclose this conflict of interest to their perspective clients. 

There is one quick way to tell if you’re dealing with a consultant or a reseller. A reseller’s services should be free to you because the vendor is picking up the tab by paying the reseller a percentage of the sale, or some other pre-arranged fee. You know in advance that a reseller is going to steer you toward a particular product, and you can thus take what they say with the same healthy dose of skepticism that we apply to information we receive from drug reps. 

On the other hand, if you are paying for services and recommendations, then you are dealing with a consultant who should be giving you unbiased advice. Unfortunately, a good number of consultants accept fees from doctors but then also receive referral fees from vendors for sending them potential clients. These payments may be in the form of cash, discounted hardware and software, or anything else of value. 

The EHR industry is relatively young and appears to be one of the exciting growth areas in an otherwise slumping economy. But this has resulted in a Wild West-like frontier where the various players (eg, vendors, consultants, resellers, state and local groups, and other agencies) can say just about anything without disclosing anything. And many IT companies and other consultants (even physicians seeking to earn some extra money) have agreements with software companies to receive payment for steering potential clients toward a specific vendor. Surprisingly, many of these otherwise honest people feel that if they aren’t specifically asked if they receive compensation from vendors (whether it be for directing leads, providing a recommendation, reselling, or even providing consultant services to the EHR vendor), they don’t need to share this information with their client or colleague. 

You need to ensure that the information you receive from these “experts” is unbiased and based on the reasonable approach of matching your practice’s needs with the available solutions. A few key steps could save you tens of thousands of dollars in hardware and software expenses, not to mention the frustration of being cajoled into purchasing an overpriced and unusable EHR that you’ll regret later: 

• When considering an EHR consultant, ask them pointblank if they have any relationship with one or more vendors, and ask exactly how those relationships work. 

• Ask the consultant how many practices of similar size and specialty they have helped in the past, and get at least three different practice names and contact information to confirm that they were pleased with the consultant, would recommend their services, and would use them again. 

• For smaller practices, be especially wary of consultants who also sell IT hardware and/or technical support. In my experience, IT consultants tend to recommend significantly more complex (and expensive) hardware and software than is necessary for the average small medical practice. 

The third point deserves a bit more discussion, since many of the consultants in the EHR space also provide IT services and sell computers, servers, and other hardware. The main problem with hiring an IT consultant for guidance is that all too often these technologically -minded people push equipment and policies that are significantly more expensive and complex than is reasonable to run a small practice. 

In my experience as an EHR vendor, all too frequently when an IT consultant is used, the practice ends up not only spending much more on hardware than my non-IT-consultant practices, but they have much less of an understanding of their system and thus an inability to troubleshoot issues that arise from time to time. In fact, Amazing Charts (my EHR company) recently raised prices for additional providers because we found that larger practices tend to have overly complex technology infrastructures based on the recommendations of their IT consultants. These systems take more time and energy to troubleshoot, and much more frequently, hardware and network issues are the source of the difficulties that lead to downtime. 

Even big companies can be guilty of up-selling unnecessary equipment to small practices. For example, Amazing Charts used to recommend our users contact Dell to get advice and affordable systems. While Dell certainly makes good and affordable hardware, many of our clients called Dell and ended up directed to Dell telesales representatives who regularly scared them into purchasing big servers, tape backup systems, and other equipment because they were a “medical practice.” Most of the up-selling of robust servers and other equipment is completely unnecessary if you perform regular data backups and follow basic networking guidance. 

When a consultant does recommend a specific product, whether an EHR system or anything else, do some online research to find out what others have to say. The American Association of Family Physicians (www.aafp.com) has a good site for researching EHR software (ie, the Center for Health IT). Message boards can be another useful research resource, if you have time to sort through all the garble. 

The most important take-away from this month’s column is to make sure that your independent EHR consultant is not actually shilling for someone else. Get it in writing so you have some legal recourse if you make a purchase and have buyer’s regret a few months later.

Editor-in-Chief of MDNG: Primary Care/Cardiology Edition

. He is a Clinical Assistant Professor of Family Medicine at Brown University and president of AmazingCharts.com, a leading developer of EHR software. He is also the founder and president of AfraidToAsk.com, a consumer website focusing on personal medical topics. He is in private practice in Hope Valley, RI.

You may have seen advertisements, or may already have been contacted by people who’ve promised to help you figure it all out so you can get your share of the stimulus money. Be wary.

Don't Get Fooled Again: Insider's Tips on How to Tell the Difference between EHR Consultants and Resellers

With all the recent talk about federal stimulus money, healthcare reform, hospital payments, Medicare funding, and other healthcare finance topics, it can be easy to lose sight of just how much money is involved. To help you see the big (and we mean really big) picture, we’ve created this handy graphic. (Click on the image labled "KEY" to view larger images)

How much money does it take to pay for healthcare?

Piles of Cash

Healthcare Microsharing Health IT blogger extraordinaire Phil Baumann believes Twitter’s “simplicity of functional design, speed of delivery and ability to connect two or more people around the world provides a powerful means of communication, idea-sharing and collaboration.” The question on everyone’s mind is: Can Twitter be applied usefully in the healthcare setting? Baumann says yes, and to prove it he wrote a blog post that listed 140 healthcare uses for Twitter, including:

• Coordinating preoperative, perioperative, and postoperative care (among pharmacy, nursing, and surgical services) 

• Crowdsourcing for healthcare resources 

• Daily health tips from authoritative sources 

• Psychiatric “check-ins” for patients 

• Data collection for tracking facility patterns (process-performance, supply-chain and staffing problems) 

• Posting quick nursing assessments that feed into EMRs 

• Ethical, permission-based following of patients

http://philbaumann.com/2009/01/16/140-health-care-uses-for-twitter

This website focuses on “generating and sharing knowledge about anemia as a serious condition” for healthcare professionals who treat patients with anemia. Tools available to assist professionals in treating anemia include the first and only clinical guidelines for the diagnosis and treatment of anemia in a family practice context; a collection of free patient brochures, videos, and display holders for use in your office or waiting room; and the 

, an overview of leading-edge research on anemia from recent publications.

The AMA Roadmap for Clinical Practice Series: Case Studies in Disease Prevention and Health Promotion 

Improving Adolescent Immunizations: A Primer for Physicians

Designed to assist healthcare providers with the issues surrounding vaccinating adolescents by examining the new recommendations for adolescent immunizations and the rationale behind them. The program includes a monograph that reviews payment, maximizing rates of immunization, and ways to enhance relationships with adolescents and their parents. 

Improving Immunization: Addressing Racial and Ethnic Populations 

Provides background information, practical recommendations and solutions to commonly encountered questions that physicians face from diverse patient populations, and case presentations for improving healthcare delivery.

Assessment and Management of Adult Obesity

A series of 10 booklets that offer practical recommendations for addressing adult obesity in the primary care setting.

Introduces the concept of population-based medicine as a strategy for reducing health disparities and integrating disease prevention and health promotion into routine medical care. It suggests actions that physicians can take with their patients in clinical settings and with the community as advocates for action that will help to close the gap in existing health disparities.

WikiHealthCare is The Joint Commission’s interactive forum for healthcare professionals. It is designed to enable and encourage discussion and collaboration among all users for the purpose of improving healthcare quality. The purpose of WikiHealthCare is to “foster collaboration among tens of thousands and in due course of time millions of healthcare professionals,” serving as a network, linking individual users to each other and to resources that can help them meet their needs. The Performance Improvement pages link users to research (evidence-based practices, resource materials, and links to a wealth of resources) on specific topics, as well as real-world experiences posted directly by other healthcare professionals.

Telemedicine and Telehealth: State by State

 Visit this site to find a full-color map of the United States; click on any state to find a concise telemedicine profile of that state that indicates whether state Medicaid reimburses for telemedicine (and which private insurers in that state do as well), reviews licensure requirements for practicing telemedicine in that state, lists relevant organizations and programs, and more. 

 Whether you are just starting to use health IT in your practice or are an old hand when it comes to EHRs and e-prescribing, you’re sure to find useful information and advice among the 11 modules offered at this site. Beginners can learn about the benefits of health IT, criteria to keep in mind when selecting an EHR system, and steps they can take to reduce practice workflow disruptions. Physicians with health IT already in place can learn how to evaluate and improve their systems, explore important health IT standards and organizations, and read more about privacy and security concerns. 

 OpenClinical is an international organization that has been created to promote awareness and use of decision support, clinical workflow, and other advanced knowledge management technologies for patient care and clinical research. This resource is a “one-stop shop” for anyone interested in learning about and tracking developments in advanced knowledge management technologies for healthcare such as point-of-care decision support systems, and “intelligent” guidelines and clinical workflow. 

 Dr. Fungus is an independent website dedicated to providing a wide range of scholarly, peer-reviewed contemporary and historical information regarding fungi. The site seeks to promote an understanding of fungi and the ways that fungal diseases of humans, animals, and plants affect people living throughout the world. Dr. Fungus offers information to both professionals and the public by making a broad range of mycology-related images and content instantly available via its website.

NEJM Perspectives Roundtable: Redesigning Primary Care

With Thomas H. Lee, MD; Thomas Bodenheimer, MD; Allan H. Goroll, MD; Barbara Starfield, MD, MPH; and Katharine Treadway, MD

In a roundtable discussion moderated by Dr. Thomas Lee, four experts in primary care and related policy—Drs. Thomas Bodenheimer, Allan Goroll, Barbara Starfield, and Katharine Treadway&mdash;explore the primary care crisis, as well as possible solutions for training, practice, compensation, and systemic change.

Is it dangerous for a doctor to be online?

KevinMD notes that “As more doctors are blogging, using Twitter, or are on Facebook, minding their online reputation becomes more important,” thus “it cannot be stressed enough that what you write or say online stays there forever.” His advice to physicians who can’t resist the Web’s allure? “Don’t count on ever being anonymous on the Web. It’s better to use your real name, and take a pro-active approach to your online reputation, rather than letting others define you.”

Editors’ picks for this month’s best websites, news, resources, and online information for physicians.

Check Up

We recently posted to HCPLive.com a news item titled “

The AMA and the Obama Administration Don’t See Eye to Eye on Government-run Healthcare

” and invited readers to post their thoughts and comments, several of which are reprinted below: 

First of all, I do not believe that “healthcare” is an effective term, since it can include an unlimited number of things, and is poorly defined in every argument. How many of you clearly understand what your fellow citizens are including in this rubric? Second, there is no constitutional right associated with “healthcare.” I believe we should all have access to “healthcare insurance” but I do not know the best way to accomplish that. The Medicare Act of 1965 CAUSED the explosion of healthcare inflation we experienced over the ensuing decades, and reflects the lack of understanding of consequence that characterizes politically motivated government decisions. If you read hospital bills and you see $10-30 charge for a single dose of a routine oral medication that actually costs 1/10 as much, you have all you need to know about cost shifting from Medicare/Medicaid to private insurers, and you see clearly that insured Americans are currently paying dearly for government decisions. Pass universal government-paid “healthcare” and this will shift to increased taxes—who will be overseeing quality, or medical necessity, or appropriateness of care? Remember what happened in 1984 with the RBRVS prospective payment system? Did you like that? I do not know the answers but I doubt a single-payer government system or a public option system is the solution. A better start is to keep our current insurance system, mandate individuals to carry health insurance, financially assist those who need it to pay for mandated coverage, pass meaningful tort reform, and work on prevention and wellness. 

I have worked in government systems, including VA, city, county, state, and private non-profit but heavily dependent on state and federal funding for about 90 percent of revenue. Medical care, like anything else, can be “good, cheap, or fast--pick two.” Every government system I have worked in has rationed care more than the private sector. We provide good care where I work, but do everything we can to discourage people from coming because of outrageous caseloads, onerous government-mandated paperwork, and year after year cutbacks in rates. Do you really trust the same people who brought you the IRS and the FEMA response in New Orleans to provide medical care? If you concentrate power in the hands of one group, you give up your freedom. Single payer is evil. If the government pays all the bills, they control all the care. How many of you accept Medicaid? If not, you cannot understand how intrusive and prescriptive bureaucrats can be. And why do I work in these government systems? I’m a good doc, a lousy businessman, and like caring for extremely complicated psychotic patients. 

 physician editor-in-chief Jonathan Bertman, MD, recently asked “

I’ll get $44,000 to Use an EHR? Where do I Sign Up?

Dr. Bertman, you are absolutely correct. I have had to spend hundreds of thousands of dollars over the years to implement EHRs in my practices. Some of the direct costs were for a) IT programmers; b) an MIS person; c) equipment costs; d) software upgrades; and e) cost of scribes. Indirect Costs were i) cost of training; ii) patient wait time increase (yes, technology delays patient processing); iii) employee time to scan and upload offline data (letters, reports, etc); and iv) the cost of retraining (due to turnover) and errors. I am sure that someone will come up in the future with a perfect system, but at present it will cost at least $44,000 or more to implement the EHR for every practice. The subsidy from government will help but in the end physicians will end up paying the difference. Hopefully, this will be worthwhile in the longer run due to ease of finding charts in the practice and other EHR/EMR benefits. However, in the long run EHR/EMR is very useful in medical practice.

Second Opinions

 for a decade now, and healthcare technology has changed in so many ways in those years. In the early days, our goal was to be a kind of “TV Guide to the Internet” for physicians, many of whom were just becoming aware of the resources and information available online. We catalogued the best websites for physicians and patients, interviewed the visionaries who were imagining new and exciting ways that the connective powers of the Internet could be applied to healthcare, and profiled other information technologies. As the Internet and health IT became more sophisticated, so too did our readers, incorporating these tools into daily practice. As readers’ information needs and professional interests evolved over the years, 

 kept pace, expanding our Internet-centric coverage to include now-indispensible gadgets such as PDAs and smartphones, EHRs, e-prescribing, and other applications. Change is in the air once again. From pending healthcare reform on an as-yet-unknown scale to the explosion of “Health 2.0” and social media technologies, the healthcare landscape is in flux, and 

 is adapting with the times. In this issue, you will notice several changes in both form and content. We’ve freshened up the look and style of our layouts and incorporated new graphical elements and flourishes. I think you’ll agree that our designers have really outdone themselves. Taking cues from some of our favorite design and technology journals, we’re going to explore how graphic design can not just complement text, but reinforce and transform it. 

We’ve done more than just change our style sheets—we have also reimagined the editorial content in 

We have been publishing MDNG for a decade now, and healthcare technology has changed in so many ways in those years.

July 2009

States to Obama: Give Us that HITECH Grant Money!

Meeting Spot

5 Ways Google Can Make You a Better Doctor

Bonus or Bogus? Are federal funds for health IT a true stimulus, or merely a stopgap?

Hot Topic: The AMA vs. Sermo

Don't Get Fooled Again: Insider's Tips on How to Tell the Difference between EHR Consultants and Resellers

Piles of Cash

Check Up

Second Opinions

Already in progress

The Ultimate Balancing Act

Saving for a Rainy Day: What is the Best Asset Protection Plan for Physicians?

Did You Miss Our Live Webinar? The Great Debate