DOQ-IT is coming to a town near you!

[DrWinn]

Everyone get ready to batten down the hatches. DOQ-IT (Doctor's Office Quality-Information Technology) is movintg full steam ahead. The government is moving forward rapidly to require EHRs (the new word for EMR) to collect specific types of data in a structured (codified) manner. This is supposed to be happening in conjunction with the EHR vendors, but most of the vendors haven't gotten on board (or are paralyzed by disagreement/indecision?). If there is not good industry participation/cooperation, then it has been mentioned that the FDA will become involved (you think EHR prices are high now!?). Anyway, HIMSS, the AMA, MEDEM and Dr. Brailer (from the govment) are leading the way. Fortunately (luckily), e-MDs has been invited to attend and perhaps contribute something meaningful to the process. What this all means is that EHRs will soon have to be 'tested' and certified to provide the specified data capture in the specified format. For some EHRs this will be a death blow as their architecture is not geared towards collecting structured data (ie Word macros, voice reconition, free text typing). While overall this is a wonderful thing for patient care (think CCR), it will impose some restrictions on how information is collected and may slow down documentation in certain instances. Our voice will be one of reason, that the requirements should not be so onerous as to bog down the clinical encounter. One requirement that I am a little uneasy with is the abndonment of listing drugs by Brand name. It appears that meds will be required to be listed by their generic components (for example; Trimethoprim/Sulfamethoxazole instead of Bactrim). As a clinician, this may take a little getting used to... (and with automated interaction checking, why is it necessary?)

CMS "Bridges to Excellence" are part of the DOQ-IT quality measures and will initially require specific data collection and reporting of stable CAD, Diabetes, CHF, and prevention measures. Osteoarthritis performance measures are planned for the future. Initially, providers will be rewarded for participation and compliance with best practices. The carrot is $5,000 - $20,000 for optimal performance. The stick is coming and will probably be exclusion from certain plans for failure to meet a certain minimal standard. The cost savings for better chronic disease management will more than offset the 'bonus' paid out.

I will keep the board posted as events unfold. Start honing your computer skills. The day is coming soon where EHRs will no longer be an option. If anyone has any thoughts or ideas I can pass along to the powers that be, speak up. Wouldn't it be great, for instance, if the governemnt would subsidize malpractice for offices that agreed to implement (and abide by) an EHR?... Wishful thinking, but who knows, stranger things have happened.

[pprescot]

.... The carrot is $5,000 - $20,000 for optimal performance. The stick is coming and will probably be exclusion from certain plans for failure to meet a certain minimal standard. The cost savings for better chronic disease management will more than offset the 'bonus' paid out.


And the safeguards against fraud will be....?

[mel]

David, thanks for the headsup,
I wonder who will absorb the added cost of all this? end user, vendor, patient :rolleyes: or, gov?
Will CCR require almost complete rewrite of code for many vendors?
Mel

[LGrant]

DrWinn, why will this impact Word macros and Voice Recognition?
L

[mel]

Please tell me they will not become the EHR police (http://www.doqit.org/doqit/jsp/index.jsp?main=../includes/glossary.html#EHR)
The language on the website appears quite benign.
M

[Kursk]

Dr. Winn's post makes perfect sense. A bunch of bureaucras want aggregated data so they can compare everyone and judge performance and restrict payments. Believe me they won't care one bit about how long it will take to use or whether forced structured documentation will impair the clarity of the reports/communication amongst care givers. And I am certain that just like WalMart forces suppliers to conform to their systems, we will be forced to comply at OUR COST to get any insurance payments.

We already have beautiful examples of such structured input that results in an ER visit note being output as 10 pages of complete crap that the receiving MD has to reconstruct into some sort of story that makes sense.

Docs will be forced to use the confining and stilted language offered by the database gods of normalization and will say things that really aren't true because it will be easier to document and get on to the next patient.

But because it will give the 'crats what they need with little effort on their side (numbers precrunched in a report) they will confidently move forward steering the Titantic toward that giant iceberg of reality.

Once again I have to ask how do you code a visit when you don't know what is wrong or its vague or ambiguous, especially if you don't get paid for such codes? Does this represent reality or just satisfy some preconceived erroneous paradigm forced on providers?

[alborg]

Another unfunded mandate...

But gentlemen:

We must realize that as physicians, we hold the ultimate trump card-> we can opt out of Medicare altogether and begin practicing again Marcus Welby MD medicine... i.e. cash only, compassionate care that brought many of us into the profession in the first place.

It's hard enough to get physicians to participate in Medicare; adding the complexity and cost of a Medem-like computer system would make being a physician a horrible proposition.

Regards,
Al

[DrWinn]

DrWinn, why will this impact Word macros and Voice Recognition?
L

Word macros and speech recognition are just blobs of indecipherable text to computers. To handle text and extract some sort of meaning, systems have been written that incorporate NLP (natural language processing). However, these are prone to error and therefore probably not a good idea to base treatment decisions upon.



Will CCR require almost complete rewrite of code for many vendors?
L

I believe most vendors will be able to incorporate the required changes provided they designed their systems with the idea in mind that structured data was important. Systems that just capture free text will have to be rewritten. The biggest challenge for vendors I suspect, is merging new visits (from a rewritten EMR) with old visits from their prior system. That will probably be impossible unless all old notes are signed off.


Once again I have to ask how do you code a visit when you don't know what is wrong or its vague or ambiguous, especially if you don't get paid for such codes? Does this represent reality or just satisfy some preconceived erroneous paradigm forced on providers?
L

Boy do I agree with that. Who ever decided to pay more for a definitive diagnosis than coding for the symptoms (ie unspecified chest pain) when Dx of angina or MI or GERD is still uncertain. That sends the wrong message to us - that we need to buff the chart for payment's sake. I have personally observed an opthmologist code diabetic retinopathy instead of the V code for diabetic retinopathy screening. His rationale?, the insurance co doesn't pay for screening (even though the patient was diabetic!) I contacted the insurance co and their response was, "that's the way we do it". Incredible, but insurance companies build automated payment policies largely based on Medicare policies, and their computers spit out payments only when the codes fit their neat little algorithms!!!!

On the other points, however, I believe everyone is getting a bit too paranoid. I do believe that with proper physician input, the govment will stay in line and not force unusable systems down our throats. Dr. Brailer has said as much - that he wants physicians and vendors to promulgate the standards and leave the govment out of it if at all possible. Dr. Andy Ury (CEO of PMSI) has been carrying the torch for physicians and vendors for over a year now and he has been outspoken against over-engineering the standards. At one point we were going to have to track some 1,300 data points and Andy got the academicians to back down. Physician EMR CEOs like Bill Zelman, Andy Ury, Randall Oates and myself will not stand still if we think the requirements will make EMRs too cumbersome or slow. To work CCR requires common agreed to and implemented standards, and I believe we all see the benefit of interoperable EHRs. As far as DOQ-IT, that is just disease management rules fired off and tracked by the same standards that will make CCR possible......

I hope I don't sound too much like a govment flunkie... but did everyone see the Manchurian candidate? I went to a govment sponsored meeting and ever since I have been having these dreams and headaches and thoughts that Bush knows what he is doing. Could there be something wrong? ;)

[pprescot]

... I have personally observed an opthmologist code diabetic retinopathy instead of the V code for diabetic retinopathy screening. His rationale?, the insurance co doesn't pay for screening (even though the patient was diabetic!) I contacted the insurance co and their response was, "that's the way we do it". ...

Exactly. The entire system of "coding" is so large and unmanageable, not to mention fraught with "inaccurate" coding just to get paid, that it's pathetic. And health care statistics are derived from this garbage? Yet the ICD-10 upcoming is supposed to encompass over 100,000 codes! Intel better get the Pentium going a lot faster to process that database input! But it will certainly give the insurance companies many more codes for which to deny payment.


... I do believe that with proper physician input, the govment will stay in line and not force unusable systems down our throats.

I certainly hope you're right. But I wouldn't hold my breath. OSHA started out small, now has so over-regulated the workplace you're lucky if you only have a few minor irregularities. Once the bureaucrats get started ... see ICD-10, above.


... At one point we were going to have to track some 1,300 data points and Andy got the academicians to back down.

Good! And good luck keeping that up!


... Physician EMR CEOs like Bill Zelman, Andy Ury, Randall Oates and myself will not stand still if we think the requirements will make EMRs too cumbersome or slow.

I don't know if you're at all familiar with the dept of defense CHCS system - old and outdated. So over a decade ago they decided they need a remake. Took that long for CHCS II to come in to being. Once implemented, it proved so slow it's further implementation has been delayed. And this is with using main frame servers at each post!


... As far as DOQ-IT, that is just disease management rules fired off and tracked by the same standards that will make CCR possible......

Yep. And it will tell the powers that be what percentage of your patients meet their standards. What % of post-MI patients are on beta-blockers if there are no contraindications, etc. Can't say I think this is a bad idea, but it completely depends on the implementation, the standards used (ever get 2 experts to agree very often), the sanctions, etc.


.. and thoughts that Bush knows what he is doing. Could there be something wrong? ;)

Of course GW knew what he was doing! Got us into a war we didn't need to fight a dictator who was no direct threat to us while managing to convince the great unwashed American masses that he was absolutely right and that it was Saddam that caused 9-11! Brilliant!

[BigDoc]

Dr. Winn's post makes perfect sense. A bunch of bureaucras want aggregated data so they can compare everyone and judge performance and restrict payments. Believe me they won't care one bit about how long it will take to use or whether forced structured documentation will impair the clarity of the reports/communication amongst care givers. And I am certain that just like WalMart forces suppliers to conform to their systems, we will be forced to comply at OUR COST to get any insurance payments.

We already have beautiful examples of such structured input that results in an ER visit note being output as 10 pages of complete crap that the receiving MD has to reconstruct into some sort of story that makes sense.

Docs will be forced to use the confining and stilted language offered by the database gods of normalization and will say things that really aren't true because it will be easier to document and get on to the next patient.

But because it will give the 'crats what they need with little effort on their side (numbers precrunched in a report) they will confidently move forward steering the Titantic toward that giant iceberg of reality.

Once again I have to ask how do you code a visit when you don't know what is wrong or its vague or ambiguous, especially if you don't get paid for such codes? Does this represent reality or just satisfy some preconceived erroneous paradigm forced on providers?
K, I am just reading this, what a scary thought.
B