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.

Stanley Feld M.D.,FACP,MACE

I have been talking about the effects of “Dirty Coal Plants” production of pollutants that precipitate the onset of diseases such as asthma, chronic obstructive pulmonary disease, autism, learning disorders, and attention deficit syndrome to name a few. At the present level of pollution in America, it is estimated that diseases related to Dirty Coal Plants costs the healthcare system $34 billion. With the new Dirty Coal Plants proposed in Texas and the nation, the avoidable cost to the healthcare system could triple.

Everyone is talking about a “broken healthcare system” with out of control costs. Few are trying to do anything to fix it. However, one giant step in the right direction would be to decrease the pollution in the nation and avoid diseases and the costs to the healthcare system precipitated by the resulting pollution.
There are two potential solutions. One is to produce clean coal plants using proven IGCC technology. Utility companies in general and TXU in particular do not want to use this technology because it is cheaper to build and more profitable “Dirty Coal Plants”.

Market forces drive the motivation. However, government should set parameters that are in the best interest of the people and then market forces should drive the motivation.

Thomas Freidman in his October 20, 2006 column “ Make History Arnold” states; “The reason that Mr. Bush’s call a year ago to end our oil addiction has been a total flop has to do with a struggle in his administration between foolish market worshipers led by Dick Cheney—who insist markets will take care of everything—and wiser, nuanced policy makers who understand that government’s job is to set broad goals and standards, and then let the market reach them.”

In my opinion, I think Mr. Cheney’s heart is in the right place. However, I do not believe he sees the whole issue. Adam Smith was correct to a point. With appropriate government rules market forces can be more powerful than complete government control.

The government should have something to say about these “Dirty Coal Plants” for the health and welfare of its citizens. No one has said anything yet. It looks like our political system is also “broken”.
The second solution is embodied in a comment I received for my blog “Review. What I Have Said Recently” from Jay Draiman Director of US Gas & Telecom. It is a wonderful comment. Essentially, it says we need to redirect our thinking.

Americans are a very smart and innovative people. We all understand we need to decrease our dependence on foreign oil. We also understand the oil industry is not very interested in the concept of change. There are other industries linked to the oil industry. The automobile industry has a huge investment in oil dependent cars. All the automobile support industries might not be interested in reducing our dependence on oil because they could also be destroyed by a change in focus away from oil.

We have to decrease our dependence on fossil fuel because of what it does to our environment and subsequently our health. One could think that the healthcare system would be adversely affected by a reduction in disease burden if we decreased pollution. However the physicians mission to preserving the health of our citizens. We are all for decreasing unnecessary healthcare costs by decreasing pollution.
Therefore it is to the advantage all of these vested interests and many others to either keep silent or at least be passive in demanding a change leading to the elimination of our dependence on fossil fuel.
All of us have been exposed to the potential of the kinetic energy that surrounds us. I will define kinetic energy as potential sources of energy we have available to us that have not been harnessed and will not pollute the environment. These energies include wind, sun, water and biodegradable regenerating substances. Technologies are available that make this kinetic energy easy to harness. I suspect we have been very slow at its adoption because the vested interests of the powerful groups have legacy domains threatened by a paradigm change.

It would be interesting if some bright and innovative person like a Steve Jobs or Bill Gates figured out how to generate a paradigm shift to change the conversation. I do not believe it will be done by the present powers driving fossil fuel use unless our government wakes up and does its job.

Eight year old children do not know what a typewriter or a 78 record is. CD’s will soon vanish from the universe.

I think it is about time producing electricity with fossil fuel became the dinosaur it is. The paradigm shift will create a very different world just asl PC and IPOD have.

Repairing the Healthcare System should not be far behind. I believe the stimulus to these paradigm shifts will be the virtual communities of the blogosphere. People like you and me networking and demanding change from our politicians.

I do not think it will be done by our politicians unless we stimulate them to do the right thing.

Jay Draiman’s comment deals with these energies and deserves the spot light and not simply appear in the comment section.

Dr. Feld

Jay Draiman
Northridge, CA. 91325
12-26-2006

Wake up America!!

President Bush did when he was Governor of Texas.

Time for another news quiz: Which American state produces more wind-generated electricity than any other? Answer: Texas. Next question — this one you’ll never get: Which politician launched the Texas wind industry? Answer: Former Gov., now President, George W. Bush.
Yes, there are many things that baffle me about President Bush, but none more than how the same man who initiated one of the most effective renewable energy programs in America, has presided over an administration that for six years has dragged its feet on alternative energy.

He fell asleep when he became President.

Stanley Feld M.D.,FACP,MACE

I have been distracted from my main theme, the ideal Medical Saving Account as the vehicle needed to repair the healthcare system. I have been building the case for this system of self responsibility as the mechanism to repair the best medical care system in the world. The theme is patients’ must control their healthcare dollar to repair the healthcare system.

We must develop a system of incentives where provider prices are transparent and providers compete for the patient’s healthcare dollar. We must create a system where providers (hospitals, physicians, and other healthcare providers) are forced to become efficient to compete for the patient’s healthcare dollar on quality of care and cost of care. The result will be that healthcare costs will decrease and the quality of care will increase. This is the meaning of consumer driven healthcare.

The last few weeks have been spent on the “Dirty Coal Plants” TXU is proposing for Texas. These “Dirty Coal Plants” are being proposed all over the country because of the abundance of cheap dirty strip mined coal. Presently $34 billion dollars are wasted healthcare costs to treat illnesses resulting from the present levels of pollution. The healthcare costs resulting from the proposed “Dirty Coal Plants” in Texas and around the country could easily double and perhaps triple.

The point is that Dirty Coal Plants polluting the environment result in large avoidable costs to the healthcare system. These costs can not be controlled by the patient exercising patient responsibility.

Patients will be afflicted with unavoidable environmentally caused diseases once these Dirty Coal Plants are built and operational. The Dirty Coal Plants will be operational for the next fifty years. The illnesses and costs of medical care for these illnesses could be avoided if we do not pollute our environment.

One could look at building these Dirty Coal Plants as “man’s inhumanity to man in pursuit of the mighty dollar.” I have been amazed by how many people believe that the EPA standards are the state of the art, that the present EPA rules will protect us from pollution. If the levels were a concern the EPA would change the rules. Therefore, we do not have to become pollution experts. The EPA’s mission is to protect us from any environmental toxin that might be dangerous. We have delegated the EPA as our surrogate to protect us from pollutants that could harm us.

Unfortunately, this has proven not to be true. Two court judgments have gone against the EPA rules in recent months. The EPA has for some reason loosened standards of pollution since 2000. One should question why. Our advances in technology have given us the ability to decrease coal burning pollution markedly by building IGCC Coal Plants. Our advances in understanding the medical effects of pollution have demanded that we decrease our exposure to these pollutants.

I understand our need to reduce our dependence on foreign oil as an energy source. If the new Dirty Coal Plants result in an additional $68 billion burden to our healthcare system by avoidable disease healthcare costs, shouldn’t a prudent government be investing in creating incentives for renewable sources of clean energy such as wind and solar energy? At the same time shouldn’t we be investing in creating incentives for energy conservation? We could use the extra $68 billion saved to promote these efforts.

TXU claims there are other sources of pollution such as our automobiles. Shouldn’t we create incentives for automobile companies to decrease the pollution and increase conservation of fuel for our automobiles more than they have? Look at the impact of the Toyota Prius, without incentives. Toyota is not even an American company. Toyota has created a competitive advantage for their product. Other companies have been slow to follow with as efficient a product. In fact it seems they are trying to undermine the efficiency of the product.

America is a brilliantly creative marketing country. America has created many “hypes” in my lifetime. My first recollection was promoting cigarette sales even though the cigarette companies knew they were not good for us. I could not wait to be old enough to smoke a cigarette. Recently, it is flat screen high definition television. Congress has even taken time out from their busy work to set a deadline for digital HDTV.

Why can’t Congress create incentives for us to stop harming ourselves with environmental pollution? Perhaps there is not enough lobbying money in the effort.

Why can’t Congress get smart and use its creative energy to promote the health of our citizens, rather than bending to the vested interest pursuit of the almighty dollar resulting in more pollution and more medical costs to society.

It can only be done if the politicians, the government officials, and the government agencies are challenged by the citizens they are supposed to be serving. It is clear to me the evolution of the rules in our legal system and the institution of lobbying has removed citizen input for demanding what is in the citizens best interest.

The time has come to express ourselves. The citizens of Texas are trying to do that right now. However, we have a very refractory Governor Rick Perry and a very powerful corporation in TXU. TXU has not demonstrated any corporate community responsibility to date. I hope our legislative officials in Austin will be able to respond to the cries of the citizens and force this folly to stop!!

Stanley Feld M.D.,FACP,MACE

I could not understand why some intelligent people do not oppose the proposed building of 17 Dirty Coal Plants in Texas. They are not impressed with any of the information I provided in the last 5 blog posts.

Finally, it dawned on me. The issue is complex. We have been told Texas needs energy to grow and be economically progressive. Coal is abundant since we are strip mining the Powder Basin in Wyoming. The pulverized coal is the dirtiest coal available with high sulfur and mercury content. This is to say nothing about the controversy regarding strip mining and the effect that it has on the topography of the land.

Natural gas has gone up in price. We want to decrease our dependence on foreign oil. Coal is cheap. We have done little to support and subsidize renewable energy such as solar and wind. Why not? These are clean energy sources that we have in abundance. I believe an intensive effort by our country could go far to harness these potential energy source. Solar and wind could provide cheap electricity while stimulating the growth of the economy.

I had an epiphany as I sat and listened to the arguments in support of The proposed Dirty Coal Plants. There is an obvious disconnect between what seems logical to me and what I have heard.

The decisions for building these Dirty Coal Plants are in the hands of businessmen, lawyers, and politicians. Lawyers, politicians and businessmen should not make medical decisions. They readily admit they do not understand medicine. However when the EPA makes a rule that is the “law” and the lawyers’ and politicians’ job is to interpret and enforce the law even if the law is wrong or inadequate.

I am for free enterprise and a market driven economy. Texas is a bell weather state that has grown and been energized by free enterprise and the free market. I am proud of it.

However, the free market should not disregard the health of our citizens, our water supply, and our food chain. This is the corporate community responsibility that we as a state and as a nation must demand.

TXU considered that they received a mandate from Governor Perry to provide increased electricity to the state for its expected growth in demand and the growth of the state in the future.

TXU set out to answer that demand and applied for 9 coal plants in rural Texas. The plants were designed to comply with EPA rules. These Dirty Coal Plants supposedly comply with EPA rules.

One should ask two important questions. Are the EPA rules stringent enough for what we know about the pollutants emitted by the Dirty Coal Plants? Is TXU building the cleanest possible coal plants for the state of Texas?

I understand the arguments of TXU and the proponents of the Dirty Coal Plants. TXU’s goal is to provide the cheapest electricity to Texas at the lowest price. In order to do this they have to build Dirty Coal Plants because natural gas is expensive, and strip mined coal from the Powder Basin in Wyoming is cheap. The old technology of these Dirty Coal Plants makes them easy to build and will provide a good return on TXU’s investment. TXU claims to be a good neighbors and would not hurt us.

TXU claims that the EPA and the TCEQ (Texas Commission on Environmental Quality) are the scientists and make the rules. They are protecting us from TXU harming us. TXU is simply complying with the rules that the experts made. These rules are the law. The state and local government have to comply with the law. The statement eliminates a lot of thinking on the part of the citizens of the state. In short it says “just trust us”.

We have seen our administration, our government officials and government agencies make mistakes recently. These mistakes were made even though information was available to avoid the mistakes. The information was either not communicated or ignored.

We have been informed that the FBI and CIA have not communicated with one another in the past. Both agencies had the composite information about 9/11. The 9/11 terrorist attack could have been stopped if these two agency were communicating effectively. The lack of communication spans the watch of at least two federal administrations.

CIA intelligence about Iraq was either incorrect or defective. The new CIA had no agents on the ground. Why did we not find Weapons of Mass Destruction? If Iraq had them, where did they send them? We absolutely know they had weapons of mass destructions during the Gulf War. We bombed a munitions depot without knowing it. The result was we poisoned 100,000 of our own soldiers and countless Iraqis and Kuwaitis’ without knowing it until the Gulf War Syndrome was described by Dr. Robert Haley of University of Texas Southwestern Medical School a few years ago.

Why did our agencies not understand the geopolitical nature of post war Iraq to predict the recent chaotic events? I submit we did know but they were not communicated to the decision makers or the decision makers did not listen. How could our military make so many mistakes and our diplomats be so inefficient?

The Katrina disaster is another example of lack of communication or inefficiencies of our government agencies. Why was the Corp of Engineers was not listened to when they told the Federal Government how badly the levies needed repair or rebuilding? Why was FEMA not able manage and administer the orderly repair of the flood’s damage and the resettlement of displaced people. Some of those people still do not have adequate temporary housing.

How can one say the EPA rules are correct when on close reading they not only are contradictory but they continually delay the reduction in coal plant emissions with each subsequent set of rules since 2000? These changes in rules result in less stringent air quality controls. Are the emissions getting better for our health? They reduction in control of emission is occurring despite their own commissioned outsourced reports declaring the dangers of present control levels.

It unfortunate that the EPA rules contradict themselves. In 2000, the National Academy of Science was commissioned by the EPA to figure out the minimum toxic dosage of mercury. Their answer was .1 microgram /Kg per day. Therefore a 22 lb child with a growing brain exposed to 1 microgram per day would be receiving a toxic dose of mercury. An average fetus weighs zero to eight lbs. The placenta concentrates mercury from the mother and transports large doses to the fetus. Population studies estimate that 7% of our new borns are affect with abnormal brain development resulting in autism, attention deficit syndrome and degrees of mental retardation. The incidence is highest in mercury polluted areas. Seventy percent (70)%) of our mercury contamination comes from our presently operating Dirty Coal Plants. The human effects of mercury contamination are clearly dose response related. Some individuals are more sensitive to lower doses than others. There should be little to no mercury in the environment.

TXU claims these Dirty Coal Plants reduce mercury output from an average of 800 lbs per year for the existing Coal Plants to 160 lbs per year per coal plant for the new coal plant. TXU is very proud of this 80% reduction and so it seems is the Texas Commission for Environment Quality. TCEQ has granted TXU provisional permit pending the result of the fast tracked public hearings.

There are two problems. The first problem is 160 lbs of mercury converts to 72,480,000,000 micrograms of mercury emitted per new Dirty Coal Plant per Year. The 2000 report said you only need .1 microgram per kg per day of mercury for it to be toxic. The second problem is mercury does not go away. Therefore, year after year this dose is additive.

I also discovered reading the EPA’s literature that one of the by products of burning Powder Basin Coal is Uranium 238. The Uranium 238 is a great source for enriching nuclear fuel. The amount of Uranium by product is more than the minimum amount allowed for a nuclear reactor by the EPA. Yet the EPA does not require measurement of uranium as a by product by these new Dirty Coal Plants. What we do not know will not hurt us. Is that correct? I would think TXU is certain not to measure uranium in the sludge if it is not required to.

There are lots of defects in the EPA rules. Is it possible the rules are inadequate? I think it is likely. In order to clear all this up before disaster strikes again we need to slow the fast track permitting process. If we absolutely need to burn coal for energy, gasification plants are need. Coal Gasification Plants are not experimental as TXU claims. Coal gasification plants can reduce mercury emission by 94% of what the present proposed plants can.

I have not even discussed the toxic effects of sulfur, nitrogen, dioxin. The EPA has not even regulated CO2 emissions. The EPA’s inadequate regulations are going to be accepted by the judges, lawyers, businessmen and bureaucrats as the law despite the deficiencies in the regulations and grant permits to build Dirty Coal Burning Plants. Coal Plants we will bestuck with for 50 years.

The evidence to me is overwhelming. We need to change the law before we allow these plants built.

The EPA is our scientific surrogate. Yet it seems to be ignoring the scientific evidence that states the present regulation are going to harm the health of our society. Do you think the EPA is immune from making a mistake? This administration and other government agencies have made mistakes in the recent past.

It is pretty clear to me that we must speak up for our sake, our children’s sake and our grandchildren’s sake.