Stanley Feld M.D., FACP, MACE Menu

Information Technology in Healthcare

Permalink:

How To Manage Complexity?

September 25, 2011
inChronic Disese Management, Consumer Driven Health Care, Information Technology in Healthcare, Medicine: Healthcare System, Stakeholder Mistrust
• Leave a comment

Stanley Feld M.D., FACP, MACE

 Complex systems are the result of interactions of experiential learning system and complicated learning systems. Complicated learning systems are created by scientific innovation. Managing the interaction effectively results in efficiencies and success.

On November 11,2007 I wrote about Mechanism Design and the Healthcare System. This Economic Theory won the Noble Prize that year. Few people have ever heard of the theory of Mechanism Design.  

Many of the stakeholders in the healthcare system have some excellent ideas. I would include Dr. Donald Berwick and President Obama on that list.  Problems usually arise from conflicting ideology and method of managing the complexity of competing ideologies.

The key is to align all the stakeholders’ vested interests in a fair and equitable way. It is important for all the stakeholders to agree with the method of managing the complexity created.

It is important to start a sensible discussion on how to Repair the Healthcare System. President Obama has a very difficult time the forcing adaption of his plan to Repair the Healthcare System because of conflicting ideologies.    

The managing of the healthcare system and it many complicated parts have to be approached in a different way.

 The key question should be who is the healthcare systems customer?

The people are the customer. President Obama’s believes the central government is the customer.

Consumers and physicians believe President Obama’s Healthcare Reform Plan is punitive. President Obama has disregarded their views.

I wrote in 2007,

“Last month the Nobel Prize in economics was awarded to Leoid Hurwicz, Roger Meyerson and Eric Maskin . They were awarded the Nobel Prize for developing the economic theory of “Mechanism Design.” My first reaction was “what is that?”

After some research I realized the power of Mechanism Design. It is a brilliant economic theory that could solve many of our economic problems. Mechanism Design applied to our healthcare system could solve most of the dysfunction.

What is it? “ In economics, mechanism design is the art and science of designing rules of a game to achieve a specific outcome, even though each participant may be self-interested.

Everyone in a free country tries to defend his/her vested interest. It is noble to defend the vested interest of others. Unfortunately, it does not work in reality. Rules can be constructed to serve all the stakeholders vested interest with consumers being the key stakeholder.

 Setting up a structure in which each player has an incentive to behave as the designer intends does this. The game is then said to implement the desired outcome. The strength of such a result depends on the solution concept used in the game. It is related to metagame theory, which is the theory of games the playing of which consists of developing the rules of another game.

This is a complex thought. If the rules of the metagame are impossible to comprehend, follow or are total opposed to the participants’ vested interest the fallback position is the rules of the first game.

Mechanism designers commonly try to achieve the following basic outcomes: truthfulness, individual rationality, budget balance, and social welfare.

This should be the goal of everyone in a rational society.

 However, it is impossible to guarantee optimal results for all four outcomes simultaneously in many situations, particularly in markets where buyers can also be sellers

A rule to the advantage of the seller can be a disadvantage to the buyer. The stakeholders need to figure out an appropriate tradeoffs.

 Thus significant research in mechanism design involves making trade-offs between these qualities.

The tradeoffs can be reasonable. They must be shown to be to the advantage of all the stakeholders.

 Other desirable criteria that may be achieved include fairness (minimizing variance between participants' utilities), maximizing the auction holder's revenue, and Pareto efficiency. More advanced mechanisms sometimes attempt to resist harmful coalitions of players.”

Pareto efficiency can be understood in the following graphic.

  Parero efficiency

 In essence when stakeholders are fighting neither B or C neither wins nor achieves total victory. The result is approximately position A. If managing complexity can convince both B and C they would be better off in position D the system has aligned incentives. Both are better being at position D.

 “Looking at the Production-possibility frontier, shows how productive efficiency is a precondition for Pareto efficiency. Point A is not efficient in production because you can produce more of either one or both goods (Butter and Guns) without producing less of the other. Thus, moving from A to D enables you to make one person better off without making anyone else worse off (rise in Pareto efficiency). Moving to point B from point A, however, is not Pareto efficient, as less butter is produced. Likewise, moving to point C from point A is not Pareto efficient, as fewer guns are produced. A point on the frontier curve with the same x or y coordinate will be Pareto efficient.”

Lodi Hurwicz contributed the idea of incentive compatibility. His point is the way to get as close to the most efficient economic outcomes is to design mechanism in which everyone does best for himself or herself. He says this can be achieved by sharing information truthfully (Price Transparency). It is easy to understand that some people can do better than others by not sharing information or lying.

Truthful information (Price Transparency) is a huge issue in the healthcare system. Hospital systems, physicians, drug companies, pharmacies, the healthcare insurance industry and the government hide behind the opacity of information.

There is a mutual distrust among stakeholders.

This mutual distrust must be overcome and price transparency achieved before any progress can occur.

Everyone claims they are afraid to be sued because of regulations. Tort Reform and regulation simplification is a must for price transparency.

If everyone’s incentives are aligned you have a much more efficient economic system. An example is defense contracting. If you agree to pay on a cost plus basis you have created incentive for the contractor to be inefficient.

 I you agree to pay a fixed price you can come close to an efficient price if you have all the truthful information. If you do not you have a fixed price and price transparency with incentives aligned, you create the incentive to be overcharged.

 The fixed pricing in healthcare must be flexible for all stakeholders. All the variables cannot be controlled during a disease process.

The variables are the patient’s responsibility for their own care, the skill of physicians to guide that patient's care and the ability to communicate information (Technology/ electronic communication) with patients and other stakeholders to increase the efficiency of the first two variables.

Most people can do better by not sharing truthful information. If the rules of the game require truthful information you can get close to an efficient market driven solution.

At present there are several impediments to ideally increasing efficiency. In fact, the incentives are present to decrease efficiency. There are numerous examples where central control has not increased efficiency.

Patients are the consumers of healthcare. Consumers must drive the healthcare system. This is the only way to maximize efficiency. 

 

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone. 

Permalink:

It Is Easy To Forget

September 21, 2011
inDefective scientific studies, Disinformation and the healthcare system, Information Technology in Healthcare, Innovations in Healthcare, Medicine: Healthcare System, Stakeholder Mistrust
• Leave a comment

 

Stanley Feld M.D., FACP, MAACE

 It is easy to forget all the promises President Obama made in order to get support his healthcare reform plan.

“If you like your health insurance, you can keep your health insurance.” That was the promise made to millions of Americans by President Obama and leaders in Congress many times in assuring them that the new health law would not disrupt the coverage they have now.”

President Obama will not be able to fulfill this promise because he cannot manage complexity.

The inability to manage complexity results in unintended consequences that lead to more complexity and in turn other unintended consequences.

 I mentioned the importance of developing Learning Systems in my blog, which discussed defective assumptions made to implement of Accountable Care Organizations. A reader asked with “What do you mean by developing Learning Systems?”

 There are three types of Learning Systems.

  1. Experience
  2. Complicated-scientific
  3. Complex –pattern visualization

The first type of Learning System is learning by experience. In medicine, medical students, interns and residents get experience from patients with the guidance of senior physicians. Physicians make future medical and surgical decisions based on this experience.

Sixty years ago the experience Learning System was the only learning system available for the practice of medicine.

As technology advanced and the cost of healthcare increased it was obvious physicians had to systemize healthcare in a scientific way as Deming systematized industrial methods in Japan in the 1950s. This movement led to the need to practice evidence-based medicine.

Systematizing the practice of evidence-based medicine is not easy. Rapid medical discoveries change evidence-based medicine. Medical practice must be prepared for rapid cycle changes.

 This second learning system is known as complicated-scientific. Complicated- scientific learning must be combined with experience learning to be effective.

 The success of evidence-based medicine is grounded in principles common to engineering. In the Learning Healthcare System envisioned by the Institute of Medicine's (IOM) Roundtable on Evidence-Based Medicine, evidence emerges as a natural by-product of care delivery, which is thoroughly documented, pooled for continuous monitoring and analysis, integrated with insights from related studies, and fed back seamlessly to improve the consistency and appropriateness of care decisions by clinicians and their patients.

The third type of Learning System is the development of the abilities to visualize and manage complexity many interacting systems.

 Complexity management is the ability to visualize the patterns of interactions created by the various systems in order to align stakeholders’ vested interests.

 Peter Senge’s “The Fifth Dimension” and my brother Charlie Feld’s “The Blind Spot” have recognized the importance of managing complexity by pattern recognition. Pattern recognition is visualizing the interplay of experiential learning and complicated scientific learning. The visualization can lead to a shift in thinking and strategy among stakeholders. When patterns are recognized it can lead to the avoidance of conflict and unintended consequence.

It is vital to the success of all disciplines in the 21st century.

 Political systems are comprised of both experience and social scientific learning systems. President Obama has ignored the complexity developed by these interacting systems. By ignoring pattern recognition of complexity he has created unintended consequences that are destroying his agenda for healthcare.

Perhaps this is intentional and his goal is to destroy the healthcare system. The void could then be filled with his Public Option and complete government control of the healthcare system.

 This brings us back to President Obama’s promise to the American people. “If you like your health insurance, you can keep your health insurance.” 

Most large companies thought they would be able to keep the present healthcare insurance for their employees. In fact, many employers believed President Obama’s assurances that their health plans would be “grandfathered.” This promise was a key reason leading to their support or to their taking a neutral stance on passage of his healthcare bill. 

Employees valued their health coverage. They were not opposed to Obamacare. Surveys showed that 88% of Americans were satisfied with their health coverage. 

As soon as both employer and employee realized that President Obama’s assurance was not going to be fulfilled most opposed Obamacare.

The grandfathering rules are severe. Employers cannot make changes to their health plans to remain grandfathered.

Employers;

• Cannot significantly cut or reduce benefits.

 • Cannot raise co-insurance charges.

 • Cannot significantly raise co-payment charges.

 • Cannot significantly raise deductibles.

 • Cannot significantly lower employer contributions.

 • Cannot add or tighten an annual limit on what the insurer pays.

 • Cannot change insurance companies. (This rule was later amended to allow employers to switch insurance carriers as long as the overall structure of the coverage does not violate other rules.

Employers will be forced to comply with expensive Obamacare regulations that increase their health costs further to maintain healthcare insurance.

 Most employers had to make major modification to their healthcare plans such as increasing deductibles to keep their healthcare insurance costs down. These companies are no longer eligible for grandfathering. It is much cheaper for them to pay the penalty than comply with the rules and provide healthcare coverage.

 The healthcare insurance industry increased premiums by 15-39% in order to comply with rules such as providing insurance to children up to age 26, insuring everyone on the group plan regardless of preexisting conditions and not rescinding coverage after enrolling a participant  

 This is an example of not managing complexity effectively.

 On top of all that President Obama issued new limits on insurance coverage. In 2011 the limit must be at least $750,000 per enrollee. In 2012, the limit will have to be at least $1.25 million, and in 2013, $2 million. In 2014 there is no limit on payouts for any individual’s care.

No one will be able to afford to provide healthcare insurance coverage especially the federal government.

The restrictions have led to President Obama issuing 1,578 waivers from Obamacare. The waivers primarily cover limited benefit plans offered by employers and unions who said the higher cost could force them to drop insurance coverage. This is another unintended consequence.

These regulations have increased business uncertainty. It has also increased mistrust of President Obama.

 The most significant unintended consequence is hesitation on the part of companies to create jobs.  

Health costs are directly related to creation of new jobs. Employers continue to face a fragile economy. Higher health costs put additional pressures on companies’ bottom lines. It increases the cost of hiring new workers and in turn discourages job creation.

 This is bad news for President Obama, the economy and unemployed workers. 

 All of the unintended consequences are a result of President Obama and his administration not understanding patterns of systems interaction. It has resulted in not managing complexity of complicated systems and increases in unintended consequences.

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone. 

  • Thanks for leaving a comment, please keep it clean. HTML allowed is strong, code and a href.

Permalink:

Does Medicare Have The Claims Data To Get The “Crooks”?

September 18, 2011
inDisinformation and the healthcare system, Information Technology in Healthcare, Medicine: Healthcare System, Stakeholder Mistrust
• Leave a comment

Stanley Feld M.D., FACP,MACE

I have opposed Medicare’s use of claims data to evaluate the quality of medical care. Quality medical care is the goal that must be achieved. However, no one has described the measurement of quality medical care adequately.

Physicians recognize when other physicians are not performing quality medical care. Physicians recognize when another physician is just testing and performing procedures to increase revenue.

These over testing physicians are a small minority of physicians in practice.

Quality medical care is not about doing quarterly HBA1c’s on patients with Diabetes Mellitus. Quality medical care is about helping patients control their blood sugars so their HbA1c becomes normalized. It is about the clinical and financial results of treatment.

The clinical and financial results depend on both patients and physicians. Patients must be responsible for managing their intake of food, exercise and medication. Physicians are responsible for choosing the right medication at the most cost effective prices and teaching patients how to control their intake and their exercise. This can be accomplished by a team approach with the physicians Diabetes Management team. The patient must be at the center of the team.

Medicare’s medical claims data does not provide this connection of the clinical information with the financial information.

I am not opposed to the use of claims data in identifying physicians, hospital systems and hospice or home healthcare organizations potential fraud. Potential fraud can be spotted by medical claims data by recognizing outliers.

The Wall Street Journal, in conjunction with the nonprofit Center for Public Integrity, attempted for nearly a year to obtain a Medicare database, the Carrier Standard Analytic File. The database contains 5% of all beneficiaries, and includes all doctor claims that Medicare paid directly in association with their care.

 It focuses on doctors and others paid on a fee-for-service basis.

The Journal and CPI wanted the data at no cost under the freedom of information act. The government wanted $100,000 for eight years of data. The Wall Street Journal and the Center for Public Integrity sued the government for the data.

The Journal and CPI obtained the requested data at a substantially reduced price and agreed not to name individual physicians or patients.  

The government lost a lawsuit to the AMA in 1979 and had been required to keep secret monies paid to individual physicians by Medicare. The AMA has continued try to defend this ruling, 

The government is not barred from revealing the monies paid to hospitals, hospices or home healthcare agencies. This information about hospital, hospices and home healthcare agencies is difficult to come by.

Former House Speaker Newt Gingrich has been screaming for years that the database should be public as long as patients’ and physicians’ identity is kept confidential. "Our estimate is that the federal government, in Medicare and Medicaid alone, loses between $70 billion and $120 billion a year to crooks. You ought to be able to identify those."

 "It's very hard to defend ignorance and willful hiding of data in the 21st Century,"   

Newt Gingrich estimates that physicians are the biggest crooks in the system. If we lived in a price transparent ecosystem, we would be able to tell if he is correct. It would be important to know which stakeholder (physicians, hospitals, hospices, and home healthcare organizations) abuses the system the most.

The Wall Street Journal and the Center for Public Integrity in studying the database made available to them found government records suggesting one family practitioner in New York City collected more than $2 million in 2008 from Medicare.

According to experts who have examined her records, her pattern of billing strongly suggests abuse or even outright fraud, She consistently performed wide array of expensive tests that suggests she has been overcharging and over testing.

 The procedures included polysomnography sleep analyses, nerve conduction probes and needle electromyography procedures. She is a doctor of osteopathy certified in family practice as well as hands on treatment called “manipulative therapy."

Eighty-nine percent of her patients received 29 tests. Fifty-six per cent of her billing came from these 29 tests. 13.1 procedures cost $2,048 each.  The antifraud authorities have flagged her for special scrutiny.

I found something strange about these numbers. Medicare only allows a certain number of dollars for certain tests. Medicare does not reimburse the tests that are not approved for certain diseases. I do not know anything about “manipulative therapy” except that it is an alternative therapy that is based upon manipulation and/or movement of one or more parts of the human body

I assume that Medicare approved this therapy and approved the charges for these tests since Medicare paid for them. Procedures and laboratory tests must be correlated with approved diagnoses. This physician might have a large manipulative therapy practice doing approved testing. She has figured out a system to generate a good return within the rules of the system.

The real issue should is not discussed. Did Medicare make a mistake in approving payment for this treatment and these tests? If so, the tests and treatment should not be approved nor paid for by the government.

The physician administrators at Medicare who approve these tests, procedures and treatments are sharp people. They use evidence-based medicine to make reimbursement decisions.

There are reasons to suggest there is more to this story than meets the eye.

 Never the less it is an example of how the Medicare outcomes medical database can be used to discover outliers. After the outliers are discovered, appropriate investigation must be done to discover why the physician is an outlier.

The real problems to be solved are ending the added cost of defensive medicine through tort reform and ending the additional costs of retesting by physicians and hospitals. .

President Obama has done nothing to decrease these billions of dollars in additional cost that add little value to patient care.

 

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone. 

 

 

 

 

  • Thanks for leaving a comment, please keep it clean. HTML allowed is strong, code and a href.

Permalink:

September 7, 2011
inConsumer Driven Health Care, Information Technology in Healthcare, Medicine: Healthcare System, Stakeholder Mistrust
• Leave a comment

E-Prescription Final Rules

Stanley Feld M.D.,FACP,MACE

Physician participation in President Obama’s E-Prescription mandate has been poor. Physicians do not like mandates.

The new final rules were published in the Federal Register on August 30,2011, CMS added new "significant hardship" exemptions. The exemption qualifications were broadened. Physicians who qualify for exemptions will not be penalized starting January 1, 2012.

CMS also agreed to extend the application for exemptions one month until November 1,2011. The number of physicians who qualify for bonus has not been published. The number of physicians vulnerable for penalty has not been published. CMS hopes that many physicians will apply for the exemption.

In an August 10, 2008 blog post I warned that the E-Prescription program as written would not work as outlined.

 I said,

When is congress going to learn that punitive action is not a wise course to pursue against a vital workforce? Real incentives work. Bogus incentives always fail.

My e-prescription plan would provide physicians incentive to use the software because it would be free and driven by their patients demand. 

The U.S. Senate on July 9 passed legislation to revise several Medicare provisions and authorize incentive payments for use of electronic prescribing technology.

Please note the complexity of President Obama’s schedule. Physicians have learned that anything incomprehensible is an administrative trick to reduce reimbursement.

 Therefore, they do not participate. If they do not participate the incentive fails. It is similar to the art of war. You simply do not show up to fight.

The bill calls for Medicare incentive payments for e-prescribing of 2% in fiscal 2009 and 2010, 1% in 2011 and 2012, and 0.5% in 2013. Sec. 132. Incentives for electronic prescribing.

Physicians despise mandates. The questions that arose are:

 2% of what?

Will it cover my cost of installing an E-Prescription system?

What is the Obama trick play here?

Does the government want to develop an easy way of following my prescribing habits so they can reduce reimbursement?

The law

  1. Provides positive incentives for practitioners who use a qualified e-prescribing systems in 2009 through 2013.
  2.  Requires practitioners to use a qualified e-prescribing system in 2011 and beyond.
  3. Enforces of the mandate achieved through a reduction in payments of up to 2% to providers who fail to e-prescribe.
  4.  Prohibits application of financial incentives and penalties to those who write prescriptions infrequently.
  5. Permits the Secretary to establish a hardship exception to providers who are unable to use a qualified e-prescribing system.
  6. Requires more reporting by physicians. The increased reporting consists of any e-prescribing quality measures established under Medicare’s physician reporting system.

“Beginning in 2012, payments to physicians not electronically prescribing would be reduced by 1%, then 1.5% in 2013 and 2% in subsequent years.      

I believe congress is mistaken if they think this will work. It will be costly to the healthcare system and someone other than physicians will make some money. The plan will only generate more mistrust among physicians for the government.”

The old rules were confusing, cumbersome and duplicative. CMS published reasons for the easing of qualifications for exemptions.

 "After we published the 2011 Medicare Physician Fee Schedule Final Rule last fall, we heard about additional circumstances that could keep physicians and other health professionals from being successful e-prescribers," Patrick Conway, MD, chief medical officer and director of CMS' office of clinical standards & quality wrote in a blog post on the final e-prescribing rules.

 "For example," he wrote, "some providers weren't sure whether certified electronic health record technology that the Medicare and Medicaid EHR Incentive Programs require is also a 'qualified' electronic prescribing system as required by the Medicare eRx Incentive Program. [Other] providers brought up additional hardship situations that the 2011 MPFS final rule didn't address."

 The 2012 hardship exemptions in the final rule cover eligible professionals who:

  • Cannot electronically prescribe due to local, state, or federal law or regulation or have limited prescribing activity.
  • Are not a physician, nurse practitioner, or physician assistant as of June 30, 2011 and do not generally have prescribing privileges.
  • Are located in rural areas without sufficient high speed Internet access or in an area without sufficient available pharmacies for electronic prescribing.
  • Additionally, organizations that have already registered to participate in the Medicare or Medicaid EHR Incentive Programs and adopt certified EHR technology do not have to prove that they are successful e-prescribers, since that program already requires meaningful users have e-prescribing capabilities.

 CMS needs the cooperation of physicians. It also needs to save face for conceiving this complex, incomprehensible, bureaucratic mandate.

"The biggest issue was [that] the eligible professionals did not want to have to deal with the payment adjustment for 2012. We think there's an attempt here to do that. Given the current environment, the providers are still feeling squeezed overall. To have them go through the adjustment in 2012 really wasn't fair," she said.

 CMS is attempting to make it easier for providers to apply for exemptions. It has added an online tool to its site. Physician practices, however, still have to submit a written letter by November 1,2011 to receive the exemption..

If congress voted for my Ideal Electronic Medical Record it would avoid the barrier of high cost of physician entry into the program. 

An E-Prescription component could be integrated into the Ideal Electronic Medical Record solving two problems at one time. Logic has not prevailed thus far.

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.  

 

 

  • Thanks for leaving a comment, please keep it clean. HTML allowed is strong, code and a href.

Permalink:

Some of Obamacare’s Complicated Mistakes

August 10, 2011
inEMR, Information Technology in Healthcare, Medicine: Healthcare System, Stakeholder Mistrust
• Leave a comment

 

Stanley Feld M.D.,FACP,MACE 

President Obama appointed Dr. Donald Berwick as head of CMS during the congressional recess last August. It was my impression it was a one-year appointment. He does not seem to be leaving anytime soon.

 President Obama made this appointment to avoid congressional hearings and the publicity of disapproval.

 Dr. Berwick’s goal for healthcare reform is a single party payer. He also believes in redistribution of wealth. I believe Obamacare will be repealed either by the Supreme Court or the next election.

 CMS’s execution of their initiatives is poor.

 Dr. Berwick believes in increasing bureaucratic structures to administer central control over physicians and their patients by regulations and penalties. 

 Accountable Care Organizations are not a bad idea if they could work. They would increase the measurability of good care. There are too many organizational barriers in the way of execution of ACOs.

Physicians and hospital systems will be fighting with each other over distribution of reimbursement and quality care judgments. Family practitioners and internists will be fighting with specialist over the distribution of reimbursement. I do not believe physicians will be satisfied with a salary determined by hospital systems.

Patients will suffer as access to care decreases. Federal funds will be wasted and the federal deficit will increase further.

ACO’s are in really HMO’s on steroids. Patients were dissatisfied with HMOs in the late 1980s to early 19990s.

The Pay4Performance formula creates penalties and not incentives for physicians and hospital systems. There are no incentives or penalties for patients’ performance.

Health Insurance Exchanges are supposed to be a way to increase insurance availability for patients who are uninsured. It is in really the “Public Option” in disguise. The Exchanges will turn out to be very costly. They will increase the federal deficit as well as state budget deficits.

 The states are objecting to the Health Insurance Exchanges for two reasons. The federal government is trying to shift the economic burden to the states while decreasing state control over of their insurance policies. HHS has even threatened to take total control of the Health Insurance Exchanges. 

 

Electronic Medical Records remain too costly for physicians. EMRs are not completely functional despite President Obama’s $100 billion dollar subsidy. Most hospitals and physician offices are trying to comply with the government mandate. The subsidy is not enough to purchase the best EMR.

No one has acted on my suggestion to put the ideal EMR software in the cloud and charge hospitals and physicians by the click. A fully functional universal Electronic Medical Record would be available instantly at an affordable cost.

These are some of the layers of complexity. I predict these initiatives will not be fulfilled by 2013. There are too many new things to adjust too all at once. All the initiatives need a reason for total cooperation.

Making things worse is the requirement to use ICD-10 to file claims. 

ICD is a claims coding formula going into its tenth iteration in 2013. It is much more complex than ICD-9.

 “The differences between the two versions are significant. Whereas ICD-9 CM provides approximately 13,000 diagnosis and 3,000 procedure codes, the version of ICD-10 diagnosis and procedure codes to be deployed in the United States are roughly 68,000 diagnostic codes and 87,000 procedure codes.”

 In January 2009, HHS and CMS mandated ICD-10 codes be used by all healthcare plans, providers, and clearing houses for all diagnosis and inpatient procedures effective October 2013. It seems like there would be enough time to adjust. However, healthcare system adjustment will be huge.

“ICD-10 is one key piece to the overall success of the larger puzzle. More granular

Data will better reflect the patients’ condition and help us manage their care better. At least, that’s the idea.”

I do not think ICD-10 will happen in 2013. These initiatives are federal mandates. They have two things in common. They rely heavily on IT, both for transactions and analytics, and they impose significant changes on organizational workflows, specifically those of clinicians.

 Any workload changes are difficult to adjust to. Too many changes at once are lethal to an initiative.  Dr. Berwick’s timing introducing the changes will be lethal to the changes. When this change comes at physicians from so many different angles they become passively aggressive and resist change. 

 ACOs, Electronic Medical Records and Health Insurance Exchanges fulfillment is behind schedule. ICD-10 will also be behind schedule.

 CMS has declared the ICD-10 compliance date will not be moved.

 • The vast majority of respondents (72%) believe ICD-10 will have a positive impact on quality in the long term.

• While they see the long-term benefit, many respondents (41%) also believe ICD-10 will strain physician relationships.

 • Most (60%) expect short-term cash flow to be negatively impacted both in terms of project resources and lost revenue. 

• Only a third of the respondents believe payers will be ready by October 2013 and most believe physician cooperation will be their biggest barrier.

 Although the knowledge that ICD-10 is coming has sparked action by healthcare leaders—most (84%) have started their ICD-10 projects—as a group, less than a third (29%) have moved beyond the assessment phase into implementation.

 ICD-10 is creating many levels of complexity to coding. It will require an increased office staff along the care continuum. The staff must learn and use the new diagnostic and procedure codes. It will also require someone to assign appropriate codes that reflect physicians’ notes. Someone will be needed to create an appropriate claim for the medical encounter. ICD-10 will increase overhead as reimbursement decreases. It is naïve to believe the EMR will automatically accomplish this

Unquestionably, ICD-10 introduces an added layer of complexity to the multitude of challenges for physicians and hospital systems that are already at hand as a result of Obamacare.

 ICD-10 puts revenue at risk for the sake of data the government might use misuse.

 I predict physicians will not participate fully. The physician shortage will intensify as more people enter the healthcare system and fewer physicians are available to treat Medicare patients.

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone. 

 

 

 

  • Thanks for leaving a comment, please keep it clean. HTML allowed is strong, code and a href.

Permalink:

The Failure Of The British Electronic Medical Record

May 22, 2011
inEMR, Information Technology in Healthcare, Innovations in Healthcare
• Leave a comment

Stanley Feld M.D.,FACP,MACE

 The development and use of an electronic medical record is extremely important for communication, rapid diagnosis and clinical decision making, increasing efficiency in working up patients, decreasing the cost of duplication of testing and time delays in medical care and treatment.

 There are many other advantages of using a functional electronic medical records. A person could be anywhere in the world and have his medical information immediately available. The results of all testing should immediately be communicated to the treating physician. All imaging studies should be digital.

Patients’ physicians could immediately read and use them for their clinical decision making.

These are only a few of the advantages of the electronic medical record.  During an office visit the physicians’ cost of removing a chart from the shelf, dictating a notes and pasting lab results into the chart is $7.75. Instant automatic noes and laboratory testing delivered to the chart by electronic medical record cost nothing.

Dr. Don Berwick the head of CMS loves the English system. England has a  a single party payer system of socialized medicine. The healthcare system is controlled by the taxpayer-funded National Health Service (NHS). The NHS committed itself to installing a fully functional electronic medical record in 2002 with the goal to have it completed by 2005. 

“Not one of England’s 250 hospitals has a full electronic records system in 2011. A rollout promised for 2005 will not now be complete by 2015.”

It is easy for government to visualize the value of a fully functioning EMR. The execution of the EMR has proven to be nearly impossible even in Britain’s homogenized healthcare system.

“Of the original big four suppliers, only BT, which is responsible for London and a few hospitals in the south, would remain.” 

 

 “Richard Bacon, a Conser­vative member of the Commons public accounts committee, told Mr. Cameron that the programme, which is years behind schedule, would “never deliver its early promise” of a record for all 50m patients in ­England.”

Of the £11.4bn budget, some £4.7bn is still unspent, he said, and, rather than “squander” it, a better way had to be found to spend it.

Only 44 of 250 big hospitals have received a partially functioning new electronic medical record system after trying for 8 years.  While the installed systems have contributed some functionality they are not fully functional. They cannot fully exchange information.

“The US-owned Computer Sciences Corporation – which is responsible for installing the system in two-thirds of the country but, by a mile, holds the programme’s record for missed deadlines.”

 The installations of EMRs have frequently led to initial chaos in hospitals. There are reports of lost patients, lost records, an inability of hospitals to be paid for the care they provide.

The scope of the program for developing a functioning EMR has been decreased as a result of cost overruns and missed deadlines.  New EMRs for ambulance services and doctors offices have been eliminated.

 In April 2010, the minister then in charge – Labour’s Mike O’Brien – admitted that it would never now   deliver the promised comprehensive solution

Nowhere in the world has found the creation of an electronic patient record easy. Denmark, which has a publicly funded health system, is reckoned by many to be as far ahead as anyone. But even that small country after 20 years still has hospitals that use paper records.

There have been many unintended consequences, too numerous to list, in trying to implement the NHS’s goal for a functional EMR. The NHS has accomplished a few of its goals.

  1. The NHS was the first in the world to replace X-ray film with digital images for scans and X-rays.

     2. Half the country’s general practitioners, or family doctors, can now transfer at least some of              their records electronically to another practice when patients move.

     3.Electronic transfer of prescriptions to pharmacies is finally proceeding at pace.

     4. Six million out of 50 million patients now have a summary care record. It contains a limited list of         allergies and current medications. It makes emergency room care significantly safer.  

The NHS has a long way to go and lots more money to spend if they continue the present course.

What is the solution?

  1. Create incentives for patients to obtain their clinical information. Scan the clinical information into a thumb flash drive and carry the data on a key chain.
  2. Create incentives for hospitals and doctors to open the thumb flash drives and use the data.

This would be an instant solution to a difficult problem. The system would reduce the cost of retesting.

EMR are too expensive for U.S. physicians. Physicians are experiencing reimbursement cuts. A fully functioning system costs more than $60,000 per physician. There are additional costs such as service and upgrade fees.

If a satisfactory EMR was available the government should buy it. They should put it in the Internet cloud. Upgrades should be installed as necessary. A single integrated healthcare system wide EMR would result. Physicians should be given incentives to use the EMR. They would be charged by the click. The cloud EMR must be integrated into a physicians’ present non functional legacy systems.  

This process was used while converting to electronic billing in the 1980’s. It should be done with the EMR now. It will save everyone time and money and increase the ability to diagnose and treat patients rapidly.

 The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone. 

 

 

 

 

 

 

 

  • Thanks for leaving a comment, please keep it clean. HTML allowed is strong, code and a href.

Permalink:

The Electronic Medical Record (EMR) Stimulus Fiasco: Part 3

May 10, 2009
inEMR, Information Technology in Healthcare, Medicine: Healthcare System, Pay for Performance (P4P), Physician's Problems
• Leave a comment

Stanley Feld M.D.,FACP,MACE

 

President Obama’s goal for healthcare reform is to increase the quality of medical care, increase efficiency of medical care and decrease the cost of care. The goal is admirable. The route he is taking is wrong. In the process he might destroy the medical workforce.

The route the electronic medical record (EMR) stimulus package should take should be flexible and educational for patients and physicians. It should use modern software technology instead of subsidizing old inflexible technology that is set up to be punitive to physicians and patients to the advantage of the government and the healthcare insurance industry.

The term "quality medical care’ is used loosely. It has not been appropriately defined. The practice of evidence based medicine has been used to define quality medical care. The problem is evidence based medicine is changing daily.

A better definition should be the best clinical outcome with the most efficient financial outcome. It is assumed that practicing evidence based medicine will lead to the best clinical outcome at the most efficient cost.

Clinical guidelines are defined by “experts” interpreting evidence based medicine. I am/was one of those experts and appreciate its short comings.

Some guidelines are essential and should be inflexible. Others are ever changing and must be flexible. In bureaurocratic systems it is difficult to create flexible rules. Also, all patients are different. Clinical judgment plays an important role in treatment.

Physicians should not be penalized for using clinical judgment. Nonetheless, physicians are penalized in a pay for performance evaluation for deviating from inflexible clinical guidelines. Since some clinical guidelines are always changing the weakness of the approach is obvious.

An example of an inflexible clinical guideline is the need for rules to have a sterile operating room with sterile gowns and tools to avoid surgical infection.

An example of a need for a flexible clinical guideline should be a physician’s approach to a patient with hypertension. The goal should be to normalize the blood pressure. The goal for lowering the blood pressure to normal is to avoid heart attacks and stroke. However, if the patient’s blood pressure was elevated for a long period of time and was severe enough to compromise the renal (kidney)) blood flow, lowering the blood pressure too quickly could result in the patient having a stroke from a relatively low blood pressure. This is an example of the value of clinical judgment.

Physician performance should not be evaluated on static measurements. It must be evaluated on physicians’ medical judgment. Clinical judgment is a function of a physician’s ability to relate to his or her patients. (patient physician relationship)

On the other hand, if a patient felt poorly as a physician tried to lower the blood pressure to normal the patient might stop his medication without telling the physician. The physician’s workup might have been perfect and his choice of medication may have been excellent. This physician might get an excellent mark on his performance but the patient had a stroke because the patient did not comply with treatment. The patient might not have complied because he was not taught to be a professor of his disease. Healthcare is a team sport. The patient physician relationship failed but was not measured. .

The poor performance was missed by the static digital healthcare evaluation imposed by an inflexible EMR. The importance of the patient physician relationship and not including patient responsibility in the clinical outcome should be part of any performance measurement. A performance measurement should be a measurement of both the patients’ and physicians’ performance.

Now that the federal government plans to spend $50 billion to spur the use of computerized patient records, the challenge of adopting the technology widely and wisely is becoming increasingly apparent.

There is no question we should have universal electronic medical records. It should be a teaching tool for patients and physicians. The EMR should be inexpensive and flexible. It should not a tool to judge and penalize clinical performance. President Obama is being ill advised. His EMR stimulus program is going to result in a waste of $50 billion dollars.

“In a “perspective,” Dr. Kenneth D. Mandl and Dr. Isaac S. Kohane portray the current health record suppliers as offering pre-Internet era software — costly and wedded to proprietary technology standards that make it difficult for customers to switch vendors and for outside programmers to make upgrades and improvements.”

The software the government is going to spend $50 billion dollars on is going to be too expensive, inflexible and not widely distributed.

“Instead of stimulating use of such software, they say, the government should be a rule-setting referee to encourage the development of an open software platform on which innovators could write electronic health record applications”.

EMR software platforms in the cloud should be developed. This link by Christopher Barnatt  is an excellent utube explanation of cloud computing. I suggest all watch it.Amazon uses the cloud to sell books. www.Salesforce.com’s business model tracks sales force activity at a minimal cost to the company. It is flexible and maintenance free.

“Such an approach, they say, would open the door to competition, flexibility and lower costs — and thus, better health care in the long run. “If the government’s money goes to cement the current technology in place,” Dr. Mandl said in an interview, “we will have a very hard time innovating in health care reform.”

The rules can be immediately changed. The cost to a medical practice could be minimal. Its effectiveness is maximal. The cost to the government using modern software technology could be between 1-10 % of what the stimulus is proposing to spend. If it is fashioned as an educational tool to patients and physicians the payback will be maximal, quality of care will improve and the cost of care will decrease.

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone

  • electronic medical records • March 10, 2010

    Thanks for such a great article to share with.I think computerized medical records will save us all:save time,reduce errors,it helps us avoid redundant tests, gather huge amounts of data for research and etc.As medical billing software said” it is also for the betterment and advancement of health care”.

  • Medical Practice Management Software • June 7, 2010

    Excellent stuff. Many thanks for sharing this informative resource. In my opinion there are lots of benefits in using Medical Practice Software. It helps in improving patient care and saves time as well as money.

  • •••
  • Thanks for leaving a comment, please keep it clean. HTML allowed is strong, code and a href.

Permalink:

The Electronic Medical Record Stimulus Fiasco: Part 1

April 29, 2009
inEMR, Information Technology in Healthcare, Medicine: Healthcare System, Politicians,Healthcare and Vested Interests, Stakeholder Mistrust
• Leave a comment

Stanley Feld M.D.,FACP,MACE.

All of President Obama’s goals are commendable. The United States needs to fix the education system, decrease its dependency on fossil fuel, increase production of renewable energy, and repair the healthcare system.

These are all big ideas. They must be implemented for the United States to prosper in the future. I have expertise in (healthcare). President Obama’s route to achieving healthcare reform is wrong. He is not attacking the basic problems in the healthcare system.

A PriceWaterhouse Cooper study showed $1.2 trillion dollars is wasted on defensive medicine and administrative costs. Where is malpractice reform on President Obama’s list of big ideas to eliminate the practice of defensive medicine?  If the $1.2 trillion dollars of waste were eliminated we would have an affordable healthcare system.

The administration’s stimulus package for instituting an electronic medical record (EHR,EMR) is going to create more waste and a larger mess than the fiasco that already exists.

“A recent Robert Wood Johnson survey of more than 3,000 U.S. hospitals found that only 9% were using electronic health records (EHR). “The numbers are disappointing and certainly lower than we thought when we went into this study,” says Ashish Jha, the lead author of the study and an associate professor of health policy and management at Harvard University. “

The survey is a well done. Survey responses were received from 63.1% of all acute care hospitals that are members of the American Hospital Association. This is a high percentage response rate for a survey. The survey looked for the presence of specific electronic-record functionalities. More discouraging than the 9% figure is only 1.5% of U.S. hospitals have a comprehensive electronic-records system (i.e., present in all clinical units and fully functional).

Only 7.6% of acute care hospitals have a basic system (i.e.present in at least one clinical unit). Computerized provider-order entry for medications has been implemented in only 17% of hospitals. Larger hospitals, urban area hospitals, and teaching hospitals were more likely to have electronic-records systems than small hospitals in smaller cities. Most of the hospitals spent over $100 million dollars for it EMR. The money spent did not enable the hospital systems to implement a fully functioning EMR.

Hospitals and hospital systems are experiencing financially hard times during this recession. They cannot afford the capital requirements and high maintenance costs to implement the installation of an EMR when the end result is not having a fully functioning electronic medical record. Hospital systems board of directors are not interested in going deeper in debt when the government is going to reduce reimbursement for non compliance.

PriceWaterhouse Coopers’ analysis of the stimulus package for EMR points out government subsidies are through the traditional EMR acquisition channels. Their analysis highlights the government’s punishing actions of non compliant providers. It is going to reduce reimbursement as punishment. Isn’t that silly? The government should be worrying about the financial health of these institutions and physicians’ practices

“The stimulus funding for health IT is a small carrot compared to the amount of resources it will take to deploy this technology over the next 5 years. Also, providers will feel a big stick of financial penalties if they fail to use government-certified electronic health record (EHR) in a government-certified manner beginning in 2015.”

It should be obvious that every physician’s office and hospital system should have a functional electronic medical record. One must wonder how physicians feel when they cannot afford an EHR that will probably not have full functionality.

Who will be the winner? Patients should be the winner. Patients will not win under President Obama’s stimulus package.

“With billions in new funding and government regulations, the health IT market will balloon far beyond the provider segment, providing new opportunities for health plans, pharma companies and other vendors.”

Powerful secondary stakeholder with financial vested interests will win.

The net result is will not be a universal and functional EMR. There will be little connectivity.

The government should invest in the purchase of a web based fully functional EMR with all the attributes necessary to build an effective electronic medical record system. The system would provide complete interconnectivity to physicians, hospitals, pharmacies, and insurance companies. Upgrades and maintenance of the software would be automatic and free.

The government would charge each provider entity by the click for the use of the universal Electronic Health Record. The government would recover its investment over a very short time and instantly create a system of price transparency. The system would be affordable to the healthcare providers. The present stimulus plan for EMR is going to waste the $36 billion dollars. It will try to force hospital systems and physician offices to buy an electronic medical record system that they cannot afford, do not want and might not work.

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.

  • Jay Beaulieu • May 28, 2009

    As an IT worker I am also worried about the President’s Healthcare IT reform. First thing I’d like to set straight is that you presented a serious series of issues about Healthcare IT and I’m going to try to address them. I don’t stand to benefit at all from my solution. I also tried contacting the Obama administration and sent the following viewpoint that implied SOA (XML contracts, workflow) and DITA (data views, procedure workbooks) both are open source, but received no response:
    I want to keep this letter at the concept level and not get into a technology whitepaper, but rest assured everything I’m about to suggest is at the cell-phone level of cost for physicians, a little more at the hospital level because of different needs but most importantly the technology already exists.
    There are currently three basic types of medical records, paper medical records, the folder we all know so well, the electronic medical record used mostly at hospitals, think of a printout from a computer system and the Electronic Medical Records (EHR) which are XML-based records that have the ability to reduce costs and errors because they are programmable and can be validated (checked for accuracy and completeness.)
    The first discussion we need to have is who should hold these records. If the goal is to fight disease, find new cures, to identify epidemics and to use these records as a basis for an unparalleled growth of healthcare knowledge over the next ten to fifteen years, we need the records easily and securely accessible. There are two groups that I think have the ability to deal with the billions of pages of medical records. The first is the Federal Government but due to the boom and bust of the budgetary process I prefer the telecoms because they are big enough, have the redundancy, the geographical reach, the competition, the bandwidth and their business model is based on providing reliable services at a low cost.
    Next we need to look at what is the correct paradigm to use for our medical records. This is simple it’s an electronic loose-leaf notebook that mimics a paper folder but has pages that can be forms or entire computer systems like an MRI system. A simple example would be using the Kindle II to access medical records. Because most physicians medical records are in paper form we need to get them scanned into electronic form and sent to the telecoms. This is labor intensive but requires little training; we could use the workers already being assembled for the 2010 census, providing a very quick stimulus effect across the country. This is not make-work because the unfiltered raw data is the most valuable form of information to researchers if searchable. The census worker leaves behind a scanner, a printer driver (to write to the telecoms) and an electronic certificate of use that allows secure and audited, reading and writing to the medical record. The electronic certificate of use controls the type of information the holder can view or update. For instance, a state worker that monitors lead levels may be able to add a report to the book but never read any information and the same would be true of a Department of Children and Family welfare worker. This information could have a direct impact on treatment choices. The census worker also performs an audit of what software systems that are currently in use at the office, for later when we convert to XML.
    At the hospital level we could use the same type of system as at the physician’s office but here since money is available we want to make use of it for future efficiencies. So the first step is to think of each computer system, medical device and medical personnel’s duties as steps in a workbook. The goal is not to run out and replace every computer system you have but rather to identify workflows and steps so that you can layer with an enterprise software service on top of whatever systems and procedures you are currently using. This is the best way to keep integration and training costs to a minimum. This first step sets the basis for measuring metrics across the hospital and after careful analysis selected systems could be replaced. The idea is that the use of EHR records can be implemented outside or on top of your current systems. Disk space is cheap and redundancy of information is not always a sin.
    At this point we’ve minimized the risk of movement to XML. The physician’s office has had time to adapt their workflow to electronic records, has probably replaced the paper folder racks with another examination room and may have had some cost savings. And they no longer have to worry about marrying an IT person to practice medicine. The telecoms are trying to sell all sorts of services like billing, automated reminder calls, electronic prescriptions the list is endless. The hospitals have identified its different workflows, decided where XML would benefit them and possibly received bids from different software vendors to wrap the individual systems either wholly or partially to take advantage of XML. Now it’s time to move to XML.
    The largest cost savings and reduction of medical errors comes not from the EHR record but from the workbooks. This type of workbook is really a best medical practice workflow, in it’s infancy it’s just an electronic record of symptoms, treatment and justification, sent to a third-party like a telecom. The purpose is to prevent a remake of the “Verdict” with Paul Newman except on the History Channel. But to do that the workbooks need to be created and maintained not by an individual software vendors or physicians but by a consortium of interested parties like the medical manufacturers, pharmaceuticals, medical associations, physicians groups and finally the Federal Government for an effectively rating. This allows for the creation and refinement of many backend programs that can check on the validity of treatments in so far as medical errors and options are concerned.
    Next up are the healthcare insurance providers. Because the medical community has its own very precise terminology, what’s covered, partially, wholly or not at all by an insurer can be conducted in an XML contract in a matter of seconds. This would require a law to be passed requiring it from the insurers. But it should also allow the insurers to provide an alternative treatment to the patient. This provides the patient a cost with an effectively rating and maybe a couple of different optional
    treatments so the patient in consultation with their physician makes the judgment.
    We left the medical records as electronic medical records earlier we need to get them into EHR but I’m of three minds here. The first is that we could have done the conversion when the records were scanned in and using software and our census workers create the EHR, this provides the greatest stimulus to the most people. Or we could scan them in and have the conversion done in places like Elkhart, Indiana or other areas hard hit by this recession, because most people that have worked in a factory or assembly line already have the skills needed for XML. But we could also write software programs to parse, categorize, and convert the data to EHR which would produce valuable programs that could be used outside of our medical records, to XML and Artificial Intelligence programs in general. The programs are re-executable whereas using the census workers is more of one shot deal. The other thought is that when designing the XML processing procedures it should never be pigeon-holed into what we expect to collect for information. A notebook can have anything in it but a page or maybe even a chapter could be validated but it needs to be remembered this is a data collection system that must change frequently with the pathogens and treatments out in the field. Layered from the unknown but collected (notebook) to the known (page) outside in.
    Now the medical office worker, physician and patient all check the accuracy of the EHR. From the physician’s point of view, forms can now be filled out on the hand-held device, new features or workbooks appear tailored to their specialty and particular treatments. Perhaps a table of relatives allows access or just querying the patients relative’s books for pertinent information, but of course this is up for discussion. The hand-devices could now have barcode readers, GPS units and biometric fingerprint readers for drug auditing, security and for access auditing. Deceased people’s books are constantly being sent to the National Archives or CDC for storage and research, a little like donating your body to science without the yuck factor.
    Hospitals have spent there monies wisely, have color-coded hand-held devices so they don’t bring the wrong one into the operating room. But most importantly, they’ve changed from, a who can pay and who can’t, to true cost accounting and I don’t mean in the IRS sense. But we as a society need to actually advance not to just pay as you go. So therefore, charging ten dollars for an aspirin from an IT perspective, I can’t help you. However, if the reason you’re charging ten dollars is to
    offset the fact that you have a separate DBA for each database or you need 24/7 support there I can reduce your costs significantly.
    Finally, we’ve created a series of checks and balances in our healthcare engine that should help it stop leaking oil. We’ve given everyone a haircut to one degree or another but we’ve refocused on the fact that the goal of our healthcare engine should be on providing better healthcare for ALL Americans and that profits should be earned though innovation and hard work not just by exploiting leaks in the system or clever accounting.

  • EMR Medical • February 25, 2010

    Thanks for the view through this blog. A major US survey has shown lately that majority of doctors think implementing electronic medical records is necessry at this time.

  • •••
  • Thanks for leaving a comment, please keep it clean. HTML allowed is strong, code and a href.

Permalink:

RHIOs Fail To Thrive, New Study: Part 2

June 25, 2008
inInformation Technology in Healthcare, Medicine: Healthcare System
• Leave a comment

Stanley Feld M.D.,FACP,MACE

A RHIO is a network of information (Regional Health Information Organization) of all the patients’ charts in a region. Anyone can get patient information and physician care activity instantaneously with proper authorization. The RHIO would be great if we lived in a non litigious society  and an environment of total trust. It could work if everyone would keep this information private. The data collected could only be used for the benefit of patients and physicians and not against patients or physicians.

The recent published study revealing RHIOs failures made several important points. The first being physicians and patients must feel compelled to participate.

“These findings suggest that nationwide electronic clinical data exchange will be much harder than what many people have envisioned,” Adler-Milstein said in a statement released by Health Affairs. “The expectation has been that we will have RHIOs throughout the country that bring together all the providers in their region and engage in comprehensive data exchange. In reality, we’re seeing few established RHIOs and those that are established only have a small number of participating groups exchanging a narrow set of data.”

The second important point is RHIOs must be financially sustainable. Who is going to pay for the data collection and storage? I suspect patients would pay for it in higher costs. 

“According to the article, “it is not clear whether even more mature RHIOs have a clear path to becoming financially sustainable.” Most of those RHIOs deliver results of laboratory and radiology tests to doctors, and the article says this is the where the return on investment is most achievable.”

If RHIOs are not financially sustainable then the government has to provide more funds. At a time when the government is economically stressed there are no funds for failed experiments.

“If we want RHIOs to attain the vision of comprehensive health information exchange, we need to increase our investments in them,” Adler-Milstein said. “Otherwise, many of these RHIOs will be unable to sustain themselves under the current market-oriented approach.”

 Dave Minch, Chair of HIMSS HIE Steering Committee published a stunning letter that says it all.

“As a provider who strives to do the right thing, I am not happy when people accuse the provider community of shunning data exchange simply for competitive reasons. That can't be farther from the truth.”
It is simple to point the finger at physicians. Physicians are an easy scapegoat."

 Dave Minch goes on to tell it as it is.

“We have a very large private network that encompasses as many physicians as will subscribe to it because we want our physicians to have as much data about their patients as possible. No, its not competition we are afraid of.”

Patients fear of loss privacy. Physicians fear litigation. Policy wonks who think RHIOs are a great idea might not have taken this into consideration. Once there is significant malpractice reform, adequate safe harbor rules, and appropriate physician incentives RHIOs might work.

“Note the word "private". That's our present requirement, because of the litigious nature of our society, and especially in today's economy when inappropriately disclosed data can be the meal ticket of a lifetime. If HIE is to become truly widespread, there have to be standards and there have to be safe harbors for those of us willing to pay the necessary security costs to keep our patients' data out of the hands of those who would violate patient privacy mandates. The first prosecuted security breech of exchanged data will set the industry back 10 years. And you can bet that it will happen without nationally instituted standards and protections. So, who wants to be first?”

There is nothing more to say. The government ought to fund my ideal electronic medical record. Patients ought to own and have access to their records. It should be patients who are responsible for providing their records to whomever they choose.

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.

 

 
 

  • Thanks for leaving a comment, please keep it clean. HTML allowed is strong, code and a href.