Stanley Feld M.D.,FACP,MACE

President Bush made a weak proposal to reform the healthcare system in his State of the Union address. When his administration tried to reform the over inflated DRG system from hospital charges to hospital cost the lobbying groups force the administration to back off. Price transparency is another area the administration tried to get support. This too was not acted upon. The knee jerk reaction from his tax credit proposal resulted in the following cascade of response.

The three most prominent Democratic presidential candidates all have declared their intention to move the country toward universal health-care coverage.

The government can not presently deal with Medicare and cost overruns how are they going to deal with the cost overrun inevitable with Universal Health Care. Anyone ever think about what the words universal healthcare means in a free and affluent society? What form does it take? How is it funded? What does it mean?

Sen. Barack Obama (D-Ill.) committed on Thursday to providing health-care coverage for every American within six years.

”I am absolutely determined that by the end of the first term of the next president, we should have universal health care in this country. There’s no reason we shouldn’t have that,” Obama said in a speech to Families USA, a liberal health advocacy group.”

The meaningless sound bite “universal healthcare” is going to be a big issue in next Presidential campaign. I sense neither the politicians or the public knows what the term means or what the consequences will be to the healthcare system.

“Former Sen. John Edwards of North Carolina declared in announcing his presidential campaign in December that he would back universal health care, even if it required expanding the federal budget deficit.”

“And Sen. Hillary Rodham Clinton (D-N.Y.), who as first lady spearheaded the Clinton administration’s ill-fated plan, also has made health-care coverage for all a central theme—highlighting her commitment by appearing at a community health-care center last weekend, the day after announcing she was forming an exploratory committee.”

Has anyone asked practicing physician and patients what their needs are to make the healthcare system effective, functional and efficient? Not yet! I also do not expect it to happen anytime soon.

”One of the goals that I will be presenting . . . is health insurance for every child and universal health care for every American,” Clinton said on Sunday. “That’s a very major part of my campaign.”

This is a good sound bite in “our sound bite society”. However, it is a meaningless statement.
“We expect that it’s going to play a bigger role than it ever did,” said the Democratic adviser, who declined to be otherwise identified.

Republican Governors have jumped in and offered their plans to provide insurance for everyone. . The plans are a good try. The defects in their plans are causing reaction already. No one has addressed the real problems of distorted charges, distorted insurance premiums, and incentives for preventing the complications of chronic disease. No one has addressed the issue of putting the patient in control of their own healthcare dollar in a market that is priced correctly with equality for all.

“Several Republican governors also have recently embraced the goal of health-care coverage for all.

Former Massachusetts Gov. Mitt Romney, who is expected to be a GOP presidential candidate, signed legislation requiring all state residents to get health insurance by July 1 or face a tax penalty, with the state subsidizing insurance for lower-income residents.

The conditions of insurance are being fought over as we speak.

California Republican Gov. Arnold Schwarzenegger kicked off his second term this month with a call to assure health care for all state residents.

The Repair of the Healthcare System is really in the control of the state governments. Those governments issue licenses to practice medicine, insure patients, and open hospitals in their own states. They can set the conditions for these licenses. However, I have only seen conditions set for the benefit of the insurance industry and hospitals, and not for the patients benefit. Only the patient can create a competitive market place that will control prices.

The president, meanwhile, this week offered a health-care plan of his own, (hardly a health plan) aimed at helping more Americans obtain health insurance. Bush spoke Thursday about his proposal at a conference outside Kansas City, Mo.

I agree. When are we going to learn that you can not enforce price controls? When are we going to learn that we can not control behavior or morality unless we have the correct rules and incentives? It sounds good but it does not work. Market forces and competition are the driving forces for reducing waste and inflated prices.

Is anyone listening to what has been proven a thousand times over? It does not sound like it to me.

Butler, who has studied America’s health-care system for 30 years, said he supports universal coverage, but that the current system would require a drastic overhaul and that the “costs would be staggering.” An estimated 47 million Americans have no health insurance.

To adopt a universal plan is “technically enormously difficult,” Aaron said, and would have to take into account that the U.S. has a highly diverse population and a highly diverse health-care system. It would require passage of several pieces of legislation that could take years to get through Congress, he said.

”I am not sure that even a new president and a new Congress can work through those devilish details” in the next presidential term and pass a universal plan, he said. Still, he said, if the supporters of a national plan avoid the mistakes of the Clinton administration, “they’ve got a shot.”

Will any of the above proposed solutions by politicians work?
My answer in no!! If we can not control prices with Medicare, how are we going to control prices with universal health insurance?

Stanley Feld M.D.,FACP,MACE

A few days before President Bush’s state of the Union address David Philips wrote in the Minneapolis-St Paul Star Tribune

Minnesota hospitals: Rising red ink

“The sudden, steep rise in the number of patients who can’t pay their bills is causing budgeting nightmares for hospitals.

It’s led to staff layoffs in some cases, slower hiring in others and scrimping on low-tech supplies, hospital administrators say. What’s more, insurers get charged more to make up for the losses, leading to higher premiums for everyone else.”

It is bad for the hospitals’ bottom line to care for the uninsured and not get paid. The salaries of 1 million plus annually must be paid to hospital administrators.

Thirty million of the 46.7 million uninsured could buy insurance if the price was reasonable. However, they are buying for health insurance with after tax dollars. Their premiums are also high because the uninsured as an individual does not have the negotiating power of big corporate buyers of health insurance. They also do not have other advantages of group insurance. Insurance companies must accept all members of a group even if they have a preexisting illness. Presently, a 50 year old individual male with hypertension and hypercholesterolemia would not be qualified to buy health insurance.

President Bush proposed to level the tax playing field for the uninsured and self employed.. The pre-tax health insurance premiums are essential for any significant reform. However, his proposal is misguided. He has ignored other essential aspects of the disadvantaged uninsured. He has created a monetary advantage to hospitals and the insurance industry. More people will be insured and more money will be made. He has not dealt with fixing the runaway price structure of DRGs for hospitals, price transparency, community rated insurance premiums, or indiviual negotiating power. The consumer is only minimally empowered by his proposal. I am disappointed in the President. I know he knows better.

“The President’s plan would give a $7,500 tax break to individuals and a $15,000 tax break to families who either buy their own health insurance or receive it through their employer.”

Grace-Marie Turner a leading authority on Consumer Driven Health Care has fought hard for this tax reform proposal. It is vital to provide the uninsured and self employed uninsured with the same advantages as the corporate group insurance plans recieve. She was very pleased with President Bush’s proposal. However, I feel the attempt is only one required regulation in a healthcare system that requires all encompassing structural reforms for the advantage of the primary stakeholders.

Grace-Marie Turner: “And isn’t moderating the escalation of health costs the goal? This would help even more.

As I explained in a talk to the American Benefits Council in 2005:
• There would be some relief in sight for employers, giving them and their employees an incentive to bargain for better value.
• Employers would be more likely to stay in the game if the open-ended tax preferences were limited and they could gain a new tool to control costs.
• And the uninsured would benefit from new revenue for tax credits to help them purchase coverage.

We think this is important enough that we actually produced a book about it called Empowering Health Care Consumers through Tax Reform.
A tax cap would be the right thing to do.

Most of the politicians running for office have jumped in with an opinion. It is clear to me we need some thoughtful leadership right now. None of the politicians sound as if they understand the healthcare problem. They seem to be searching for sound bites. It sounds like they simply want to get elected or reelected. The situation is a smart entrepreneurs’ opportunity of a lifetime.

Stanley Feld M.D.,FACP,MACE

The Presidential election is just 18 month away. During every political season interesting things happen in America. On January 19th the WSJ had an article entitled “Health-Insurance Gap Surges as Political Issue.”

“Suddenly, the long-festering issue of providing health coverage to the one in six Americans who lack it seems to have leapt to the top of the national to-do list.” The Journal reviewed all various politicians’ proposals to repair the system.”

.” However, “[t]here’s nothing approaching a consensus on what to do.” Some see “the current turmoil and dissatisfaction with job-linked insurance as hastening a single-payer national system,” while others “would let individuals shop for health care much as they do for other things.” Meanwhile, a “third camp, borrowing from what’s going on at the state level, essentially would widen existing sources of health insurance — government, employers and individual policies — so that they cover everyone.”

President Bush had distinct proposals in his State of the Union. The lead article in the NY Times did not report all his proposals. President Bush’s entire proposal was defective in that it gave lip service to price transparency. A system without price transparency is a system that does not generate competition. I feel his outline was too brief and the implications incomprehensible to the average citizen. It may have been incomprehensible to the average congressman and senator.

“In effect, the president is proposing a new standard deduction for health insurance — $15,000 for families and $7,500 for individuals. That would mean lower taxes for more than 100 million Americans with employer-provided coverage worth less than the standard deduction, Mr. Bush said. But it would raise taxes for about 30 million people with more expensive plans, unless they switched to less costly alternatives, White House officials said.”


Does everyone understand the above??

“Mr. Bush said the tax proposal was an effort to “level the playing field” between Americans buying insurance on their own and those who get it through their employers.”
“For the millions of other Americans who have no health insurance at all, this deduction would help put a basic private health insurance plan within their reach,” he said. “Changing the tax code is a vital and necessary step to making health care affordable for more Americans.”

The ability to deduct health insurance premiums by the uninsured is vital to solving the uninsured problem. However, it is only one initiative in a dysfunctional healthcare system. The system needs many sound structural changes introduced simultaneously to be repaired to a truly market driven competitive system.

A little step here and a little step there will only make the system more dysfunctional. These small steps will only be to the advantage of the insurance industry and hospitals. The cost of care will go up with more money in the system. CEOs of insurance companies will get richer while access to care and quality of care will go down.

“Democrats, labor unions and some consumer advocates said the proposal would shake the foundations of the nation’s health insurance system, still largely built around the workplace.”

This quoted statement shows me the profound lack of understanding of the problem the healthcare system faces.

This is precisely the reason that the consumer and not our government needs to lead the change.

The patient needs to control his own healthcare dollar in a totally price transparent environment. Some entrepreneur or some financial services organization is going to provide this option to the consumer. The result will be the all that financial gains through inefficiency and rising premiums will be toppled. I have in mind some entrepreneurs who I think could do it.

Stanley Feld M.D.,FACP,MACE

My son Brad and I have just completed our annual weekend trip together.
This year it was Las Vegas. Las Vegas has few distractions for us because we do not drink, gamble or go to strip shows.

The places we go annually are insignificant. They are simply the background for just being with each other, experiencing each other and experiencing each others intellectual and emotional growth over the past year. The karma of the experience is invigorating to me.

We do things randomly. Nothing is planned. This year there was one exception. We had tickets to Cirque du Soleil’s LOVE. If you like the Beatles this show is a knockout. The choreography and acrobatics glorifies every song. Those guys were great. It is amazing to me that four young kids from Liverpool could have such wisdom.

Brad and I continually learn from each other. There was one point in time that I was his mentor. Clearly that time has passed. He is my mentor now. It is a wonderful feeling to have a child, learn from each other as he grows up and then become buddies as he becomes an adult. Brad, I thank you for being such a great kid.

On the lighter side we found the Stage Door Deli. I had a pastrami sandwich. The goal was to compare the Stage Door Deli pastrami to the Carnegie Deli pastrami. However, when we found the Carnegie Deli another pastrami sandwich would have killed me.

The Egg Cream at the Stage Deli was a C to C- Egg Cream. They do not make them like they use to. The Carnegie Deli borscht was A+.

Las Vegas is really a caricature of America. The visual stimuli are overwhelming.

The annual bonding with my son is beautiful and unforgettable. Every father should do it with their son every year.

Thank you Brad

Stanley Feld MD,FACP,MACE

In my last post is referred to” Naked Conversations : How blogs are changing the way businesses talk with customers by Robert Scoble and Shel Israel. It is a must read.” I by error omitted Shel Israel as co author. Shame on me! I am usually very sensitive to this. I made an error. I fully appreciate the work of coauthors, and the importance of that recognition. I apologize Shel Isreal! I hope you can accept my apology.

A PMR (Personal Medical Record) is one part of the integrated EHR (Electronic Health Record I described. I received the following comment from Steven Goodman. The comment warrants inclusion because it signifies that people are thinking.

“In the medical field, EMR’s and PMR’s are vital in the forthcoming of better treating patients under any circumstances. Be it a natural disaster, like Katrina, or another terrorist attack, or even if your just going out of the country or to a place you are unfamiliar with, these portable medical records will aid in the treatment of patients. Although there is much discussion over what is invading our privacy and what isn’t, either way these devices serve an invaluable service; they will save our lives! We need to take these items from being a novelty item to becoming a necessity, something that everyone of us has. Even in my young age, I am 23, many of my friends would truly like to have one of these devices and I also have a few testimonials of friends of which this type of device would have greatly helped them. Again, PMR’s and EMR’s are a great idea and we need to spread the word!”

The Personal Health Record (PHR) is one important component of the Electronic Health Record (EHR). It is the medical record of the individual. It’s data belongs to the individual. The key to a successful EHR is that all the components listed are interoperable and relational data points. I suspect if there is only 18% adoption of the Electronic Medical Records and few that are interoperable and relational we are a long way from having an interopretable PHR.

In the ideal Medical Saving Account the patient is motivated to be responsible for their own healthcare dollar and their continuing health in order to save money tax free for retirement. The demand for the PHR will be present. The patient will be motivated to avoid costly repetition of testing and long diagnostic work up. Additionally, tests like an EKGs or a complete blood tests are simply a snapshot of the patients condition at the time of the test. Serial testing is an important help in making the correct diagnosis quickly. There is no reason that patients and potential patients can not have access to their medical history and laboratory evaluation instantly at the present time.
I have advocated that the patients obtain a copy of their history, physical and all laboratory tests and procedures from their physicians. The patient should then scan the documents into their computer. They should then copy the stored data into a USB Flash Drive Key. The Key can be carried with them at all times in case of emergency or reevaluation by another physician. Any physician’s office or emergency facility can download the information instantaneously through the USB port. The information is important for past history and rapid diagnosis .

There is no delay in record transfers. The patient collecting the data places the responsibility on the patient and not the hospital or clinic for old medical records that could be necessary at times of new illness.

The USB Key PMR is only a stop gap measure until we have an integrated EHR. It can be not only cost saving it can be life saving.

A friend, Ira Denton M.D. and his wife Judy Denton Phd created a company called Cap Med several years ago. It is an excellent integrated PMR along with and an EMR. The development was a little early in the adoption cycle. It contained a physicians perspective so vital to future success in my view. It is functional presently in several clinic. The Denton’s sold their company to a larger company. As pressure to adopt the ideal EHR build systems like the Denton’s system are out there and developed.

The problem is these systems are not formatted for the benefit of the physician and the patient. The patient has in make the decision on how the information gets distributed. Until then and until the cost is reduced, adoption by the medical profession will be slow.

In the meantime Steven Goodman, I would buy a $15 512 mb USB key, scan, download and carry your medical records in your key case at all times just in case of emergency.

You own your medical record and it is your responsibility to maintain that record. Ten years from now the institution that generated your record could have destroyed it. The information you paid for is no longer available. However, it will be present in your USB key.

Stanley Feld M.D.,FACP, MACE

I type ideas into my computer so I do not forget them. I do not know if the following is a quote from someone or something I simply wrote down. I apologize to the person if someone else said it.

A given: Free societies tend naturally toward a “Katrina mentality” of doing nothing until something happens. Have we done anything yet?

September 11 was less ‘a failure of imagination’ than an inability to see that America’s enemies were hiding in plain sight. They still are. Have we done anything yet?

The same mentality applies to developing the Ideal Electronic Health Record (EHR). The answer is in plain sight! The barriers are the vested interests that are benefiting from the present medical infrastructure. It is difficult to be innovative and imaginative when you are experiencing success. Many successful businesses feel anything innovative, imaginative or noble could decrease their present success. It is also difficult to express innovation and imagination in a hierarchical bureaucracy. Therefore “mature” businesses and organization become ossified.

The problem in a free society is you can only become chief of the bureaucracy (most of the time) if you do not use your imagination and do not make waves.

I believe the internet, and blogosphere are going to change all of the ossification of innovation and imagination our society has experienced recently. They are truly democratizing. The internet and blogosphere permit people to think, be imaginative and innovative through the ease of free expression offered by RSS.

The great power of a free society is individual freedom of speech, a free press and freedom of communication. We have lost some of these freedoms in the last 70 years with the development of hierarchical bureaucracy and consolidation of the press.

Robert Scobies’ book Naked Conversations is a must read. The subtitle is “How blogs are changing the way businesses talk with customers.” We are in the midst of a revolution in how we do business. Most of us can not visualize it yet. In general, societies do not understand the paradigm shifts as they are in the process of occurring.

In the development of the ideal EHR the answer is hiding in plain sight. I believe I established the fact that the Electronic Medical Record (EMR) should be broadened to an Electronic Health Record (EHR). I have also established the fact that the Health Savings Account (HSA) should be expanded to a Medical Saving Account (MSA)

In the Repair of the Healthcare System the key question is where does the healthcare system spend most of the money?

1.Eighty to ninety percent of the money is spent on the complications of chronic diseases. We all accumulate chronic disease as we go through life. As I said previously, medical physicians have become very expert at fixing things that are broken. The medical profession has just started to develop systems of care for chronic illnesses in order to prevent complications of chronic diseases. If we have systems of care for the treatment of chronic disease in place, and could execute the practice of evidence based medicine efficiently in a clinical setting, we could reduce the complication rates of diabetes, osteoporosis, asthma, chronic obstructive lung disease, muscular skeletal disorders, hypertension and heart disease by at least 50%. If we were perfect we could probably reduce the complication rate by 80%

The math is simple. Diabetes Mellitus costs the healthcare system in direct cost $150 billion per year. The cost of complications is eighty percent (80%) of $150 billion, or $120 billion per year. A fifty percent reduction in cost means a $60 billion dollar savings to the healthcare system for diabetes. However, the disease management has to be done correctly.

Can a system of disease management be set up to reduce the complication rate of Diabetes Mellitus?

It has been by the American Association of Clinical Endocrinologist for Diabetes Mellitus. Any physician can execute this system of intensive diabetes self management in his office. The most important person in the system of care is the patient. It is a system that teaches the patient intensive diabetes self management. Intensive means the patient is taught how to normalize his or her own blood sugar. A normal blood sugar will avoid the complication of diabetes mellitus. The system of intensive diabetes self management teaches the patients to be the “Professor of Their Disease”.

Patients are responsible for their own care. The physician is the coach that helps fix some errors in patients self management. The care paradigm can be put in an Electronic Health Record (EHR). Both the patient and physician can share all the results including the blood sugar tests the patient does and the lab work the physician does with a web based EHR. If the banking system can do it with online banking, medicine can do it!

The interoperability of the EHR includes a pharmacy history of the patient’s compliance with medications that are ordered. The pharmacy must interact with the patient/physician electronic health record every time a refill is given. The physician can then through the EHR calculate the patient’s compliance with medication.

Compliance is a huge problem. If the patient does not take the medication the medication can not protect against the complications of disease. If the patient is educated (patient education is under compensated or not compensated presently by the insurance industry) and is responsible for their own healthcare dollar with a Medical Savings Account (MSA), the patient will become motivated to demand and will pay for education. It is easy for patients to understand that not only is their health at risk but their own money is also at risk.

An imaginative person in an unimaginative facilitator stakeholder industry can start seeing how this one element (Chronic Disease Management) is the one answer to the run away healthcare costs. The answer is in plain sight. The current information technology expertise is available. The EHR has to be created to add value to the patient/physician interaction for both the economic and quality care benefit of the both primary stakeholders. It is inappropriate and doomed to failure if it is formatted for the secondary stakeholders. It has to be driven by the patient. It has to have interoperability between medical and financial lines. The patient has to be given incentive to drive the system.

I will continue to expand on the ideal EHR.

I will continue to build on the ideal electronic medical record.

Stanley Feld MD, FACP, MACE

In my last post a comment referred to the difficulty with Kaiser HMO’s EMR. The following was reported in the San Francisco Chronicle November 7, 2006.

“Kaiser: Critical Need To Cut Rising Costs”

“$7 billion in losses if no action taken, HMO report says”. Kaiser has invested $3 billion in data system created by Epic Systems Corp. Kaiser’s project supervisor e-mailed 180,000 employees detailing his frustration with Kaiser’s Electronic Health Record System which he considers inefficient and unreliable. The project supervisor brought his concerns to the Kaiser HMO’s board. He said the information was not taken seriously “because of conflicts among top executives.” Doesn’t this sound typical of the hierarchical bureaucratic systems we live in? One simply has to recall the problems in the CIA and 9/11. Kaiser is supposed to be the best of the best.

The creation of an effective electronic medical record is extremely complicated. Physician practices and hospitals have different needs and therefore different EMRs. In fact the EMR is just one health record. The system that is needed is an Electronic Health Record (EHR) with multiple components. There is much confusion between these two terms. The confusion leads to the hesitation by physician to adopt an EMR.

The goal is to convert medical records from paper charts to digital electronic charts. The goal is to enhance the flow of information about patients and their care to all who might be involved in the patients care. The physician’s office practice work flow is very different that the work flow in a hospital. Therefore one size EMR does not fit all in our present environment. The issue of trust in handling records between primary stakeholders and facilitator stakeholders also represents a barrier to adoption.

The theory is that a paperless chart will decrease the waste and inefficiency in the system. The handling of each chart per physician patient encounter cost the physician $7 in labor and material. One click can save $7 per chart, if there was an efficient, reliable, and affordable EMR.

However, a paperless chart is in reality worth little unless the information entered is usable in data base format rather than word processing format. Only then, can patient care be enhanced. I will explain this in detail as we proceed. Many EMRs sold are simply word processing of records. Only in a data base format can one piece of data be related to other pieces of data to truly decide on best practices for enhancing quality and decreasing the cost of the complications of chronic disease.

There are many needs in health care information systems (Health Informatics). An electronic health record (EHR) is a personal medical record (EMR) that can typically be accessed on a computer or over a network. An EHR almost always includes information relating to the current and historical health, medical conditions and laboratory tests of the patient. In addition, EHRs may contain data about medical referrals, medical treatments, medications and their application, demographic information and other non-clinical administrative information.

The non clinical administrative information includes the financial charges and collections. All of these data points must be able to be integrated via relational databases in order to determine the relationship between the disease or diseases, medical steps taken, charges, costs and payment in relation to clinical (medical) outcomes. To my knowledge, the ideal EHR system has not been implemented by any software company to this date.

As of early 2007, adoption of EHRs and the multiple components of EHR have been extremely slow. I believe the reason for this is because the stakeholders are unsure of what they are buying. The software companies are unsure of what they are selling or are unsure of the primary stakeholders needs. The cost of the product is also beyond many primary stakeholders’ means in a medical economy of falling prices.

Less than 10% of American hospitals have implemented semi robust Health Informatics Systems. Only 16% of primary care physician have put an EMR in place. Most of those EMR are word processors. These EMRs get paper off the table eventually and cost large amounts of money to buy and maintain. Physician find these EMRs do not do what they need and are forced to buy add-ons.
The government wants paperless records so there is portability for the patient and ease of chart inspection by the government. This represents another reason for suspicion and caution on the part of the physician.

There Are Many Types Of Electronic Records In Use Presently.

Electronic Medical Records
Personal health records (PHR)
Continuity of Care Record (CCR)
Electronic health record (EHR)

Somehow all of these electronic records have to be combined.

Interoperability Is The Key To Any Successful EHR

However, interoperability can only be exercised at the request and permission of the patient and the physician. This becomes another barrier to adoption. I made a negative comment about Regional Health Information Organizations (RHIO) a while ago. I said I did not think they would work. There are many reasons for this view. First, how is this information going to be collected? What are its potential uses? Some uses are good, but many uses are bad for the patient and physician. Remember, they are the primary stakeholders.

In the United States, the development of standards for EHR interoperability is at the forefront of the national health care agenda. I believe without interoperable EHRs, practicing physicians, pharmacies and hospitals cannot share patient information, which is necessary for timely, patient-centered and portable care. Interoperability is essential if the EHR is going to help reduce the cost of care.

I believe that Medical Saving Accounts can help this process along. I plan to develop this belief. This portability should be for the benefit of the patient and the physician. It is not for the benefit of secondary stakeholders, especially those secondary stakeholders that see a widening of net profit with these new complicated systems that someone else pays for.

Aside from administrative waste of $150 billion dollars a year, 90% of the Medicare dollar is spent on the complications of chronic disease and 80% of the overall healthcare dollars is spent on the complications of chronic disease. The elimination of administrative waste could be reduced by present state of the art healthcare informatics systems if the proper motivation was created.

However, if we are going to repair the healthcare system electronically, the healthcare informatics systems must function with fully integrated interoperability. There must be systems of continuous quality improvement built into the EHR that are not punitive to the physician or the patient.

Presently, we have a healthcare system where the electronic information (incorrect information for the most part) is punitive to the patient and the physician, and lacks interoperability or continuous quality improvement. Several software companies have the infrastructure to achieve this goal. However, they do not seem to understand the physicians’ mentality in order to reach the goal. They key question again is who is your customer? The answer is the patients (consumer) and the physicians.

The concept of interoperability systems is embedded only in the Electronic Health Record. Interoperability cannot be attained with the Electronic Medical Records software companies have available. Remember, only sixteen percent (16%) of us have bought an EMR. Most of these records are potentially out of date. The EMR has gained some efficiency, but so far short it has been far short of its monies worth to the physician, the patients, or the cost of care to the healthcare system.

I will next discuss my vision of the idea Electronic Health Record.

Stanley Feld M.D.,FACP,MACE

There is no shortage of opinions about the value of EMRs. There are a lot of intelligent people writing about the advantages and disadvantages of the Electronic Medical Record.

No one has figured out how to break the physician resistance barrier. If someone would develop an EMR that would add value to the advantage of the physician and the patient, utilizing an easy learning curve, I think the universal EMR would spread like wildfire.

First, we need an enlightened and respected leader who could force the healthcare system to face its problems, namely the inefficient costs of administration, price opacity, lack of systems of care for chronic disease, and the lack patient control of their healthcare dollar.

The inefficiencies of administration of the healthcare system by facilitator stakeholders waste $150 billion dollars a year. I can understand why a facilitator stakeholder such as an insurance company or hospital resists eliminating this waste. There is a large profit margin in waste. In order to protect this income generating inefficiency, multiple excuses and barriers to fixing the waste are constructed. These stakeholders always seem to blame the physicians and the patients for the waste.

The following two comments from nationally prominent physicians sum up the problem and perceptions about EMR of most physicians.

The first comment is from a nationally prominent specialist who at one time was the head of a 300 physician multi-specialty IPA (Independent Practice Association). He subsequently headed a large single specialty group of physicians. He had start up experience with EMRs in both practice groups. His view is cynical but in my opinion accurate.

“Stan,
The EMR is expensive awkward technology. EPIC possibly the most widely developed (in part owned by Kaiser I believe) is not user friendly, requires much administrative support and has so many bells and whistles that users empirically incorporate their own mini user protocols, essentially defeating the purpose. I disagree that physicians are particularly computer literate and believe that cost and the fact the technology is still awkward and non-standardized is a barrier. Someone is going to need to underwrite or give physicians the technology, and it better not be the VA EMR which Medicare was at one time proposing to roll out. Of course, if the technology is provided, the giver will want to be able to puts its nose under the tent and gain information, consistent with HIPPA’s provisions.
Will EMR improve patient care and safety? No question it will but I suspect it will take 25 years. Will it generate information that may or may not result in physician disincentives, possibly? Very difficult for me to believe EMR will ultimately result in benefit as defined by current vendors. New generations of physician users, however, may believe there is benefit and be unaware of the coexistence of physician disincentives.”

Those developing EMRs should pay attention. No one has developed an easy to use and inexpensive EMR. No one has explained the multiple values of the EMR measurement. Only negative and costly experiences linger. The key questions not asked are who the real customers, and what do the customers really need. In the mind of most EMR vendors the hospital, government, insurance industry are the real customer. These are the stakeholders that have the money. Physicians and patients do not have the money to invest in an EMR.

I was told this 12 years ago by the head of the medical informatics division of a large corporation. I told him his focus in my opinion was dead wrong. I predicted and his EMR would fail. It has not succeeded although they have generated some very painful experiences for all the stakeholders.

The healthcare system needs the development of an EMR that will satisfy the needs of the physician and the patient. It must be user friendly and augment rather than hinder the physicians daily work flow. The EMR can not be punishing nor have a steep learning curve.

An ideal EMR would be one we did not buy. The needs of the physician and patient would be clearly defined. The EMR would be paid for by the click, just as you pay a credit card company for adjudicating a purchase. There is no reason the patients insurance claim could not be adjudicated immediately with a credit card. The physicians would not have to pay for endless upgrades and improved interfaces. The EMR vendors would pay for their mistakes, not us. There would be continuous quality improvement in the software system at no up front cost to the user. The system would be a heavily encrypted web based system for privacy. The patient would own their own data. It would be totally portable. The more the physician uses the EMR and its financial packages the more the physician pays for its use. The patients’ electronic medical record would have to be connected to the patients’ financial history in order to evaluate medical outcomes appropriately. EMR’s will not succeed until some creative vendor realizes this and can get over his own bureaucratic hierarchy. There should be no penalty to abandon an EMR that does not work well for the patient or the physician.

The second note is from another prominent leader in medicine. He is describing the core of the problem in the healthcare system. Until we abandon our legacy systems designed to protect facilitators stakeholders’ vested interests, we are not going to get anywhere in repairing the healthcare system. We will continue to generate million dollar plus salaries for insurance company CEOs and hospital administrators who add no value to the medical care system.

“Stan
My own opinion is that, until our government guarantees adequate health care access and cost/coverage to all Americans and requires transportability of medical records for all without casting the cost for this onto the physicians, we will continue to have the same mess we now have.”

I do not think Nancy Pelosi has a clue about what needs to be done. Remember, the government is not going to solve our problems. The primary stakeholders (the patients and physicians) must solve our problems.

The government’s job is to create the conditions for patients to be responsible purchasers of healthcare with their own money in a totally price transparent environment. Then, and only then will price and quality competition take place among physicians and hospitals as well. At that time, adoption of an EMR to increase efficiency, decrease expenses and increase quality will make sense to physicians and hospitals. The EMR will be driven by the patient demanding a lower cost vendor in a price transparent environment with improved quality of care. The ideal MSA would encourage the use of the ideal EMR.

Stanley Feld M.D.,FACP,MACE

Physicians have been slow to adopt Electronic Medical Records (EMR) even though most physicians are computer savvy. There are reasons for physicians to be slow adoptors.

They are told that the EMR will increase their quality of care. However, quality of care has not been adequately defined by those who proclaim EMRs’ virtue. Physicians have negative experiences with information technology. The insurance industry and government have used IT against physicians to decrease the fees. Physicians know much of the data collected by the insurance industry and government has been formatted to answer the wrong questions. The potential of the EMR simply stimulates more mistrust and suspicion on the part of the physician against these entities.

Those knowledgeable about EMRs would say “Dr. Feld you have it completely backward.” Perhaps I do. I do not think so. I have expressed the perception of many physicians. Perception translates to the reality of resistance by physicians.

I understand the advantages of a functioning and effective EMR. If done correctly the physicians would flock to adopt the system. However, most demonstrations of EMRs are a disaster. The implementation of EMRs by most EMR companies has been worse. The purchase of an EMR to many physicians has simply been money down the drain. A few practices have been lucky and very successful.

The investment the physician must make is at minimum $50,000 per physician. In an environment of decreasing insurance and Medicare payments, $50,000 is a huge investment. In addition there is usually an annual maintenance fee as well as yearly service fee. Many software companies produce EMRs. Choosing the correct EMR seems impossible to most. Many physicians have been stung by the software company going out of business within two years, making their investment worthless.

In the January 2007 issue of Health Data Management there appeared a Newsline article “Hawaii Blues to Docs: We’ll Help with EMRs.

“A $50 million program from the Hawaii Medical Service Association, under which the Blues plan, would give providers substantial financial help to purchase electronic medical records systems, could wire up most physicians in the state.”

Why would the physicians want to be wired up? What does wired up mean?

“Honolulu-based HSMA also thinks the program will foster the longer-term goal of establishing regional health information organizations.”We’re making this investment to move the community along to wider adoption of I.T. so we can be ready for RHIO activity,” says Cliff Cisco, senior vice president. “There’s a lot of RHIO talk, but we’re a ways off from implementing a network. We want to prepare for that and give motivation.”

One should note that a RHIO is a network of information of all the patients’ charts in a regional and anyone can get patient information and physician care activity instantaneously with proper authorization. This would be great if we lived in an environment of total trust. It could work if everyone would keep this information private and would not use the data gathered against the patient or physician. Remember the social contract in medical care is between the patient and the physician.

“Under the three-year HMSA Initiative for Innovation and Quality the plan has committed $20 million toward the purchase of EMRs for physician practices. It will contribute up to half the cost of an EMR, capped at $20,000 per physician, for about 1,000 physicians.’

The physician would still have to pay $30,000 for something he does not want and he does not perceive will increase the quality of his care. It is viewed as a tool that will be used to punish him.

Cisco believes a “significant” amount of funds under the hospital program will go toward I.T., but the overall goal is to reduce practice variances and improve safety. Details of the program remain under development. “We’ve made the commitment and now are talking to hospitals,” he adds.”

Please notice the implication is the system is going to tell the physician what he should do to practice “good” medicine as defined by the insurance companies and hospital administrators. This seems like a way to generate more mistrust between physicians and the insurance industry.

“The program to help pay for EMRs is open to any physician who doesn’t have EMR software. But the focus will be on small and rural practices where adoption rates are low. HMSA hopes it will get most of these practices to take up its offer, Cisco says. “This is an effort to bring on slower adopters of the technology.”

My response is good luck!

The EMRs also will have to be certified by the Certification Commission for Healthcare Information Technology. HMSA is expected to have a list of acceptable EMRs available by the end of 2006.

If this program was perceived by the physicians as a good idea it would have to be a single uniform software program with measurable data points available to the physician for his proving an improvement in his quality of care to the patient. Multiple software vendors will increase the costs and decrease the mobility of the data collected. I will devote more time to describing the ideal EMR in the ideal MSA system. The system would greatly benefit the patient and the physician. The benefit to the facilitator stakeholders would be secondary and not punitive to the patient or the physician.

“Heavy penetration of EMRs in Hawaii could support more comprehensive pay-for-performance programs. HMSA for five years has had a pay-for-performance program that gives physicians and hospitals “modest” payments for meeting certain quality standards, Cisco says. The new initiative is much larger than existing P4P programs, he notes. “Our board thought we’d ramp this up a bit, put out this $50 million commitment and see what it achieved.”

Does anyone out there know the potential punishing effects to the healthcare system that pay for performance will inflict. In my view pay for performance is not well thought through presently. Many physicians are totally opposed to the notion because the decisions of performance are going to be made by the same insurance company administrators that used incorrect data to produce the failed punitive report card system.

This ambitious program is going in the opposite direction of the concept of the ideal Medical Saving Account. It is not empowering to the patient or physician. P4P in the present form does not provide incentive to the patients or the physicians to improve their performance. It is an administrative mechanism devised to dictate physician behavior, undo patient privacy and reduce payment.
It is sure to fail at best and generate more distrust and waste at worst. The healthcare system does not have three years to waste on this folly. The endeavor is bizarre to me. It is a waste of $50 million. I predict the $50 million loss will be passed on to the patients in the form of increased premiums
The $50 million could go a long way to create the ideal EMR in an ideal insurance system (MSA). Some smart entrepreneurial company will figure it out some day. I hope sooner rather than later.