Sunday, April 15, 2012
Electronic Prescription of Controlled Substances
The electronic prescription of controlled substances (EPCS) is a topic that has been in my thoughts lately. Next month my hospital and clinic go live with an EHR that has e-prescribing capabilities. During training I was told that electronic prescribing of controlled substances was not allowed. I recalled that an interim final rule (IFR) for prescribing controlled substances had been posted in the Federal Register in 2010. So I spoke up and said that electronic prescription of controlled substances was allowed. That started me on a search for up-to-date information about the subject. It turns out that in March 2012 in Arizona, I was only partly correct but that has changed in April 2012. Let me start by providing some information about EPCS.
EPCS offers a number of advantages over the current state of affairs. For current e-prescribers separate paper and electronic workflows are needed to prescribe the full spectrum of medications. For some specialties such as mine as an orthopedic surgeon, the majority of prescriptions I write are for controlled substances (narcotic pain medication.) Printing prescriptions for controlled substances from many eRx software arrangements requires that special alteration-proof paper be loaded into the printer. That is a disruptive workflow. Finally, EPCS could potentially help reduce the explosion of illegal use of prescription medications currently being experienced in the U.S. by providing better two-way communication of prescription history between prescribers and pharmacies .
Barriers to EPCS include lack of incentives to certify eRx software, need for identity proofing of providers to obtain a digital certificate, the relatively modest cost (less than $100 per year) of obtaining a digital certificate, and the need to modify workflow processes to integrate standard eRx and EPCS.
The IFR for prescribing controlled substances can be found here. A number of succinct summaries have been published to help understand this somewhat complex regulation. I will provide links to some websites that I have found useful. A few of the key points are discussed below. A specially certified electronic prescribing system must be used at both the provider and pharmacy ends of the transaction. (For now, the certification is separate from that for the Medicare and Medicaid EHR incentive programs of CMS.) The IFR did not specify approved certifying agencies so this was problematic. In September of 2011 InfoGard was uniquely approved for this role. It has been hard at work certifying systems since. Next, prescribers must have digital certificates and use two factor authentication to sign and submit prescriptions. The eRx vendor was supposed to provide names of Certificate Authorities (CAs) or Credential Service Providers (CSPs) with whom they work to help providers verify their identity and obtain the necessary digital certificates. The CAs and CSPs should be cross certified with the Federal Bridge. I believe this step presented a barrier because the process is fairly new in the health IT world and participating CAs and CSPs are not easily identified. Continuing, at least two individuals must be involved in setting access controls to the controlled substance eRx software. Also, the software must be able to provide an audit trail of electronic prescriptions submitted. (These two requirements seem straightforward.) Loss of a hard token (a piece of hardware used for two factor identification such as a fob or smart card) must be reported immediately. Finally the workflow specified for preparing and submitting the electronic prescription of the controlled substance is flexible enough to permit a variety of individual prescribing routines.
So almost two years after the IFR was published, what has been the real-world experience with electronic prescription of controlled substances? Remember there are times when state law takes precedence over federal regulations. (This constitutional conflict between federal and state's rights continues all these years later.) Now that a certification body has been approved by the DEA, Surescripts has worked with EHR vendors and pharmacies to offer support for EPCS in CA, TX, and VA. There must be other pilots in states where the law does not prohibit electronic prescribing of controlled substances. I don't offer a comprehensive list. I have looked into electronic prescribing of controlled substances in my state of Arizona. Last week I called a local pharmacy and the representative said the EPCS is illegal in Arizona. I looked at the State Pharmacy Board website. They had a page with resources about EPCS but stated that it was not authorized in Arizona. Then, just this past Friday, the weekly newsletter published by the Arizona Medical Association announced that the governor signed a bill that legalizes electronic prescription of controlled substances on April 4th. Now we will have to wait to see how quickly EPCS is adopted in Arizona.
Coincidently, I was listening in on a meeting of the Health Information Technology Policy Committee Privacy and Security Tiger Team last week. They were discussing the comments they plan to submit to the full committee regarding the NPRM on Meaningful Use stage 2. They decided not to comment on the lack of requirement for EPCS in the proposed regulation. I was surprised because they often talk of aligning regulations and incentives. Contrary to this decision, I think a federal regulation would present vendors with a strong incentive to spend the extra time and money to redesign their eRx software and obtain the separate certification required and move this initiative forward.
Friday, April 13, 2012
The 2011 EHR User Satisfaction Survey
One of the best sessions I attended at HIMSS 12 was the roundtable on EHR user satisfaction. The session was based on a survey of 2,719 family physicians published by the American Academy of Family Physicians in 2011.
The presentation stimulated a lot of audience interaction. I think this publication is a worthwhile reference for both those in the market for an EHR and for those who are already EHR users. Only a relatively small number of physicians participated in the survey so it doesn't represent a complete analysis of the EHR marketplace. Nevertheless, a substantial cross-section of the more popular products was evaluated. Some of the findings will be discussed below.
Practice size was an important determinant of the products being used. In other words, smaller practices tended to select vendor solutions that were distinct from those utilized in larger practices. Respondees from the smaller practices also tended to be more satisfied with their EHR products than users from larger practices. The survey did not provide a definitive answer as to why this was the case. Responses to individual questions where some of the elements of usability were broken out provide a strong clue. Some factors contributing to high EHR satisfaction included overall ease of use, ease of customization, vendor training and vendor support. Among other factors studied were documentation, ordering labs and x-rays, reviewing results, electronic prescribing, patient engagement, meaningful use tools, and communications capabilities both within and outside the practice. Some of the most popular products were unknown to me. I spent several hours visiting the websites of a number of the products discussed to garner some additional insight. The time was well-spent.
The sophistication of the website design and information available was variable. The best were transparent about pricing, offered product information and demonstrations in video format, were up-front about product certification, and provided interesting information about company history and management.
Surprisingly, one of the highest rated products is available free. Advertising is the revenue source although for a relatively small subscription fee the software is available sans advertisements. This is a web-based product that is very attractive because it requires very little local IT expertise. Also, access to the EHR is available anywhere there is Internet access.
Several of the products were distinct in having robust real-time meaningful use tools and easy-to-use reporting tools needed for attestation such as reporting core and menu requirements and clinical quality measures including numerators and denominators. Several of the companies have incorporated advanced neural network concepts in their designs to facilitate documentation and improve quality of care. This is an interesting alternative to templates or dictation for documentation and patient management. One of the companies excelled at ease of delivery of care summaries in the form of the CCD. Few vendors were upfront about how they meet this meaningful use requirement. All the vendors appeared to support electronic prescribing. Some of these modules appeared easier to use than were others. It was rare to find information about health information exchange capabilities, specifically whether the Direct Project specification and associated workflows had been incorporated natively into the EHR product. This will need to change because the use of Direct is headed for a new stage 2 Meaningful Use requirement.
The most alarming conclusions of the survey were that only about 50% of users were satisfied with the systems they were using. Frank dissatisfaction was nearly 30%. Finally, just 38% agreed or strongly agreed that they would purchase their system again. HIMSS has sponsored usability workshops at previous annual meetings. I attended two years ago and learned a lot. The Office of the National Coordinator supports a group looking at usability issues also.
The presentation stimulated a lot of audience interaction. I think this publication is a worthwhile reference for both those in the market for an EHR and for those who are already EHR users. Only a relatively small number of physicians participated in the survey so it doesn't represent a complete analysis of the EHR marketplace. Nevertheless, a substantial cross-section of the more popular products was evaluated. Some of the findings will be discussed below.
Practice size was an important determinant of the products being used. In other words, smaller practices tended to select vendor solutions that were distinct from those utilized in larger practices. Respondees from the smaller practices also tended to be more satisfied with their EHR products than users from larger practices. The survey did not provide a definitive answer as to why this was the case. Responses to individual questions where some of the elements of usability were broken out provide a strong clue. Some factors contributing to high EHR satisfaction included overall ease of use, ease of customization, vendor training and vendor support. Among other factors studied were documentation, ordering labs and x-rays, reviewing results, electronic prescribing, patient engagement, meaningful use tools, and communications capabilities both within and outside the practice. Some of the most popular products were unknown to me. I spent several hours visiting the websites of a number of the products discussed to garner some additional insight. The time was well-spent.
The sophistication of the website design and information available was variable. The best were transparent about pricing, offered product information and demonstrations in video format, were up-front about product certification, and provided interesting information about company history and management.
Surprisingly, one of the highest rated products is available free. Advertising is the revenue source although for a relatively small subscription fee the software is available sans advertisements. This is a web-based product that is very attractive because it requires very little local IT expertise. Also, access to the EHR is available anywhere there is Internet access.
Several of the products were distinct in having robust real-time meaningful use tools and easy-to-use reporting tools needed for attestation such as reporting core and menu requirements and clinical quality measures including numerators and denominators. Several of the companies have incorporated advanced neural network concepts in their designs to facilitate documentation and improve quality of care. This is an interesting alternative to templates or dictation for documentation and patient management. One of the companies excelled at ease of delivery of care summaries in the form of the CCD. Few vendors were upfront about how they meet this meaningful use requirement. All the vendors appeared to support electronic prescribing. Some of these modules appeared easier to use than were others. It was rare to find information about health information exchange capabilities, specifically whether the Direct Project specification and associated workflows had been incorporated natively into the EHR product. This will need to change because the use of Direct is headed for a new stage 2 Meaningful Use requirement.
The most alarming conclusions of the survey were that only about 50% of users were satisfied with the systems they were using. Frank dissatisfaction was nearly 30%. Finally, just 38% agreed or strongly agreed that they would purchase their system again. HIMSS has sponsored usability workshops at previous annual meetings. I attended two years ago and learned a lot. The Office of the National Coordinator supports a group looking at usability issues also.
Thursday, April 5, 2012
EHR Training, the Hard Way
My hospital is preparing to go live with a major vendor's EHR system the first of May. Hospital staff and clinicians have been busy going to training to prepare. Most of this post will be about my experiences during this training. Anyone who has read this blog knows that I tend to be on the critical side. Most of my experience has been unpleasant, perhaps because I, more than most other clinicians, know how it should/could be done.
First, you should know that I volunteered to become a physician superuser. Based on my training and preparation to teach a class on EHR adoption at the master's degree level, I had certain preconceived notions about how this would go. I was greatly disappointed to find out that most superusers being trained were not physicians. I was in a class that included no physicians in fact. Most of my fellow students were already familiar with the system because they had been enrolled in earlier courses so they had a head start on me. I was doubly frustrated because I had a lot of difficulty searching for my assigned patients. The search was done on the last name, case sensitive, and grammatically incorrect small case letters for the entire last name. It was hard to get over a life time of capitalizing the first letter of proper names. I am sure my 9th grade English teacher is turning over in her grave even now.
I had a lot of trouble following the training. It did not take me long to realize that the major reason for this was that the training was not following clinical workflow. They might train how to manage orders in the recovery room, then a discharge, and then a history and physical. I have written a post about workflow and my observations about workflow have not changed a bit. It was enlightening to learn that one of the trainers had a background in sales and never worked in a clinical environment. This does not excuse the designers of the training who should have known better. I rightly or wrongly attribute this to lack of provider input. But that ignores the fact that best practices for clinician training are well-recognized and widely promulgated.
Many of the major tasks clinicians do routinely were not covered at all. Basic things like how to order an x-ray (I am an orthopedic surgeon after all) or how to view an x-ray in the new system, how to incorporate dictation into a note ( turns out a few clinicians will use voice recognition, most will use the current dictation system if they choose) or create a hybrid note, how patients will be consented for surgery (an electronic signature device will be used) how to transfer a patient to an outside facility, how to prescribe controlled substances, how to ensure a patient receives an electronic visit summary, how to provide patient education materials, how a clinician handles the patient portal- patient emails, release of lab information, and the list goes on.
Back to being a superuser. I found the plan for training superusers was to have them take the course twice and maybe help out with people having trouble on the second go around. There was no special one-on-one or small group training, and short cuts, tips, in depth training, best practices, etc. were not covered. The executive plan appears to me to have non physician superusers help physicians during the go-live. Given the lack of physicians trained in the role this is inevitable. The question is whether it will work well. There is substantial experience to indicate that there will be a problem. Physicians do better taking advice from physicians. Even experienced nurses or unit clerks really don't know physician workflows and likely are not aware of some special needs of physicians. I will wait and report back on the success of the strategy being implemented.
I had a cloud-based practice management system a number of years back. Training was carried out via live webinars for me and my staff by the vendor's trainers. I set up my scheduling system including role based permissions, appointment types and times with this training alone. Physicians were provided very little training about the schedule function of the new software. I was not even aware of the courses that trained on the scheduling module. I like to make my own appointments when I see a patient after hours, or discharge a patient from the hospital on a weekend. I think this provides better continuity of care at a care transition. With the new system, I will not be able to utilize this functionality-by design. I get upset about such things. I dislike wasted potential to improve care and I don't like being harnessed to a receptionist or medical assistant to carry out essential tasks. It turns out that this enterprise system actually is broken up into a number of silos as far as training goes-inpatient, outpatient, financial, patient portal, administration, etc.
A number of asynchronous learning sessions were offered to doctors. I never heard about them before class even though they were assigned as prerequisites. They were accessed through an employee portal. I had never used the portal because I was not an employee of the hospital and did not have user credentials to get into the system anyway. This oversight was clear up at the end of the first class. I think it happened less frequently for physicians taking classes after me. The e-learning sessions were actually quite helpful. They were produced by the vendor using professional trainers who were experts with the system. Each session covered a vignette, an element of clinician workflow. I liked being able to watch these videos several times. Unfortunately, there were quite a number of e-sessions available. Because of the numbering system for the sessions it was apparent that only a few of the available sessions were assigned for review. Communication for physicians about the menu of available sessions was only available upon request if one figured out there had to be more available somewhere.
Everyone had to pass a test to be able to be cleared to use the system. The first time I took the test I found out I was going to be tested at the end of the course during the final hour of 9 hours of training (after hours and after a full day of work.) The test was given on paper and answers were not discussed. I failed the first time but did not know what I missed. Later, trainers covered all the questions before the test (and gave correct answers) and the test was electronic and provided the correct answers for all questions missed so that when one retook the test it was hard not to pass. I could go on with a few more complaints but I think I'll end with one more thought.
Finally, I found it surprising that there was not a single point of contact for questions about training. I didn't know whom to call for help. The trainers were so focused on their individual areas that they did not have an overview of the whole system. I did find one trainer who was able to answer a laundry list of questions I prepared after my first few classes. I appreciated his help but I was lucky to find him.
First, you should know that I volunteered to become a physician superuser. Based on my training and preparation to teach a class on EHR adoption at the master's degree level, I had certain preconceived notions about how this would go. I was greatly disappointed to find out that most superusers being trained were not physicians. I was in a class that included no physicians in fact. Most of my fellow students were already familiar with the system because they had been enrolled in earlier courses so they had a head start on me. I was doubly frustrated because I had a lot of difficulty searching for my assigned patients. The search was done on the last name, case sensitive, and grammatically incorrect small case letters for the entire last name. It was hard to get over a life time of capitalizing the first letter of proper names. I am sure my 9th grade English teacher is turning over in her grave even now.
I had a lot of trouble following the training. It did not take me long to realize that the major reason for this was that the training was not following clinical workflow. They might train how to manage orders in the recovery room, then a discharge, and then a history and physical. I have written a post about workflow and my observations about workflow have not changed a bit. It was enlightening to learn that one of the trainers had a background in sales and never worked in a clinical environment. This does not excuse the designers of the training who should have known better. I rightly or wrongly attribute this to lack of provider input. But that ignores the fact that best practices for clinician training are well-recognized and widely promulgated.
Many of the major tasks clinicians do routinely were not covered at all. Basic things like how to order an x-ray (I am an orthopedic surgeon after all) or how to view an x-ray in the new system, how to incorporate dictation into a note ( turns out a few clinicians will use voice recognition, most will use the current dictation system if they choose) or create a hybrid note, how patients will be consented for surgery (an electronic signature device will be used) how to transfer a patient to an outside facility, how to prescribe controlled substances, how to ensure a patient receives an electronic visit summary, how to provide patient education materials, how a clinician handles the patient portal- patient emails, release of lab information, and the list goes on.
Back to being a superuser. I found the plan for training superusers was to have them take the course twice and maybe help out with people having trouble on the second go around. There was no special one-on-one or small group training, and short cuts, tips, in depth training, best practices, etc. were not covered. The executive plan appears to me to have non physician superusers help physicians during the go-live. Given the lack of physicians trained in the role this is inevitable. The question is whether it will work well. There is substantial experience to indicate that there will be a problem. Physicians do better taking advice from physicians. Even experienced nurses or unit clerks really don't know physician workflows and likely are not aware of some special needs of physicians. I will wait and report back on the success of the strategy being implemented.
I had a cloud-based practice management system a number of years back. Training was carried out via live webinars for me and my staff by the vendor's trainers. I set up my scheduling system including role based permissions, appointment types and times with this training alone. Physicians were provided very little training about the schedule function of the new software. I was not even aware of the courses that trained on the scheduling module. I like to make my own appointments when I see a patient after hours, or discharge a patient from the hospital on a weekend. I think this provides better continuity of care at a care transition. With the new system, I will not be able to utilize this functionality-by design. I get upset about such things. I dislike wasted potential to improve care and I don't like being harnessed to a receptionist or medical assistant to carry out essential tasks. It turns out that this enterprise system actually is broken up into a number of silos as far as training goes-inpatient, outpatient, financial, patient portal, administration, etc.
A number of asynchronous learning sessions were offered to doctors. I never heard about them before class even though they were assigned as prerequisites. They were accessed through an employee portal. I had never used the portal because I was not an employee of the hospital and did not have user credentials to get into the system anyway. This oversight was clear up at the end of the first class. I think it happened less frequently for physicians taking classes after me. The e-learning sessions were actually quite helpful. They were produced by the vendor using professional trainers who were experts with the system. Each session covered a vignette, an element of clinician workflow. I liked being able to watch these videos several times. Unfortunately, there were quite a number of e-sessions available. Because of the numbering system for the sessions it was apparent that only a few of the available sessions were assigned for review. Communication for physicians about the menu of available sessions was only available upon request if one figured out there had to be more available somewhere.
Everyone had to pass a test to be able to be cleared to use the system. The first time I took the test I found out I was going to be tested at the end of the course during the final hour of 9 hours of training (after hours and after a full day of work.) The test was given on paper and answers were not discussed. I failed the first time but did not know what I missed. Later, trainers covered all the questions before the test (and gave correct answers) and the test was electronic and provided the correct answers for all questions missed so that when one retook the test it was hard not to pass. I could go on with a few more complaints but I think I'll end with one more thought.
Finally, I found it surprising that there was not a single point of contact for questions about training. I didn't know whom to call for help. The trainers were so focused on their individual areas that they did not have an overview of the whole system. I did find one trainer who was able to answer a laundry list of questions I prepared after my first few classes. I appreciated his help but I was lucky to find him.
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