Stanley Feld M.D.,FACP,MACE

If you ask a number of physicians to define quality medical care, most will come up with a definition close to the Institute of Medicine’s definition.

IOM Definition of Quality:

“The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”

Systems of medical care are necessary to reproduce the results of clinical trials for chronic disease. How does one develop a system of care to decrease the complications of chronic diseases? One must divided the elements of quality medical care into separate modules. The result should be the improvement of medical care outcomes.

Quality of Medical Care should be defined specifically to include all the elements of quality care. Continuous quality improvement means improving the processes used in fulfilling each element of quality care.

The elements of quality care are as follows:

1.Recognize patients at risk for diseases
2.Do appropriate evaluation
3.Make the appropriate diagnosis
4.Start the appropriate treatment
5.Schedule the appropriate follow-up
6.Stimulate the appropriate compliance/adherence to treatment

Goal is to decrease complication rate, morbidity, mortality and cost of care

Three of the six element of quality medical care can be automated by the ideal EHR. Three of the elements require physician judgment and patient participation.

1. Recognizing The Patient At Risk

The following are screening procedures to detect disease early so preventative measures can be taken:

a. Cholesterol and HBA1C measurements every 5 years if normal
b. Fecal occult blood yearly after age 50
c. Flexible sigmoidoscopy/Colonoscopy every 3-5 years after age 50
d. Clinical breast exam yearly
e. Mammogram yearly after age 50
f. Pap smear every 1-3 years
g. Clinical testiscular examination once a year
h. Digital rectal exam yearly after age 50
i. PSA yearly after age 50
Vaccines
j. Influenza yearly
k. Pneumococcal once after 65
l. Tetanus/Diphtheria every 10 years
m. Hepatitis A once
n. Hepatitis B once
o. Osteoporosis indications for bone density
WOMEN
All using steroids > 65 > 40 with low trauma fracture > age 45 with risk factors

One can easily see that the EHR can cue the physician to screening tests and timing vaccinations automatically. Automating this process of quality would increase the detection of disease early. Appropriate timing of vaccines can prevent disease. The patient could also receive advanced notice of screening procedures due through the PHR (Personal Health Record) module of the Ideal EHR.

2. Appropriate Evaluation

The appropriate evaluation is at the physician’s decision using his medical judgment. The physician’s clinical judgment is the most important element in the diagnostic decision. Options could be provided by the EHR. However, it remains the physician’s judgment. He could elect a less invasive test for some illnesses depending on the patient and the patient’s circumstances.

3. Make The Appropriate Diagnosis

The physician has to interpret the test with the patients history in mind. He has to read the studies with an expert if he has an incomplete report. There are many subtle changes in laboratory studies that indicate disease and can not be picked up by a computer. Guidelines should be provided. An example of what I am talking about is the early detection of a low bone density secondary to both osteoporosis and a vitamin D deficiency. The calcium will be normal to low or high, the phosphate low normal, the alkaline phosphatase high normal. This is a clue to osteomalacia secondary to vitamin D deficiency. Further testing is necessary to make a diagnosis that would otherwise be missed and blunt the effect of the appropriate therapy.

4. Starting The Appropriate Treatment

Starting the appropriate treatment is the physician’s decision. The evidence based medicine could be connected to the EHR. The clinical outcome of his decision could be available for his own education by the EHR.

5. Scheduling The Appropriate Follow-up

Scheduling the appropriate follow-up can be done at the point of physician service through the EHR. The physician can be guided by evidence based medicine guidelines instantly. If it is important to see the patient sooner the physician can override the guidelines and justify the visit.

6. Compliance/Adherence To Appropriate Therapy

Compliance/adherence to appropriate therapy is essential for improved outcomes. The compliance/adherence rates reported in the literature are awful. The range is 10% to 50%. There is too little emphasis on the patient’s responsibility to adhere to medical therapy. However, patients live with their disease 24 hours a day and should have the burden of being responsible to adhering to therapeutic regimes. The defect is that the patients often do not understand the significance of the therapy. Patient education is essential. Patients have to become the Professor of their disease. The physician has to be the educator himself, or with the use of physician extenders. Education by built in information to the PHR (Personal Health Record) can help. Interactive patient interactive sessions can also help. If the patient does not take the medication we can not hope for improved outcomes. The physician can track the patient adherence through electronic communication with the pharmacy to determine compliance through refill frequency. The EHR can automate this conduit of adherence.

Quality medical care is not only about evaluating patients at risk. It is only the first step in quality medical care. The other five steps are just as important. I tell physicians it is not about how many bone densities you do, or how often you measure the HBA1C for diabetes mellitus, it is about preventing osteoporotic fractures, and decreasing the complication of diabetes mellitus.
Practicing the process of quality medical care should decrease the complication of chronic disease. The translation of evidence based medicine to clinical practice is a continual process of quality improvement. The ideal EHR could help greatly in achieving this goal.

Stanley Feld M.D.,FACP,MACE

After the last post I received the following comment.

“But here’s the problem. How can you keep government agencies, malpractice lawyers, and so on from accessing an EHR? They can subpoena written records or EHR’s, but the ability of sophisticated computer users to hack into an EHR system is what gives a lot of us ordinary folks the willies.”

This is a comment that always comes up. I believe the software companies with electronic medical records can answer the question better than I can. I have asked the question of security to many software companies who create EHRs and EMRs. Their answer has always seemed satisfactory to me.

Other industries seem satisfied with the security they have. The banking industry is elated with the savings and efficiency of online banking. I should think security in banking is as much of a privacy concern of people as medical records. Paper records all over the place in laboratories, physicians’ offices and hospitals never seemed very secure to me. One of my son’s (Brad Feld) portfolio companies “Still Secure” has created a software package that creates a fence around the computer server which makes the server is totally invisible to incoming and outgoing data. The thirty four year old CEO of Still Secure, Rajat Bhargava, is one of the brightest people I have ever met.

I spoke about the EHR cueing the Primary Care Physician to evidence based medicine tests, procedures and treatments. It is practically impossible to remember all the screening procedures that need to be done while treat care of an illness that brought the patient into the office. If done automatically, this would increase the quality of medicine practiced.

The malpractice attorneys’ opportunities would disappear if the governments, both state and federal, had the courage to pass realistic malpractice reform. Unfortunately the reform is occurring too slowly and sometimes incorrectly. The practice of defensive medicine has wastefully increased the cost of medical care.

If a patient has not seen a physician in a year, then visits with a common cold, there might be several screening tests due for the patient. If the patients chart is thick, it might be difficult to find the PSA (Prostatic Specific Antigen), rectal for blood, or chest x-ray in the paper chart as there is pressure to see the next patient. In an electronic chart all of this data can be presented at point of service to the physician. The physician can then recommend the evidence based screening test to the patient. There is simply too much information to keep in one’s head. The patients can decide, with the doctors help,which screening test they want done.

If the patient went to several physicians and had a Personal Health Record, the doctor would know instantly if the patient had the test at another physician’s office. The test and treatment could be available to the present examining physician. Having this information available could serve to discover disease early, avoid costly complications and save lives.

Physicians are always checking the literature to see the latest treatments, complications or drug interactions. Most physicians have computers in their office. In recent years rather than going to their textbooks which are outdated as soon as they are published they go to Pub Med, various journals or organized medicine sites to get the latest information. To get the latest information on a drug they do not turn pages in the PDR anymore. They go to the online PDR or pharmaceutical web site. Internet access in a typical practice day can be invaluable.

In an Ideal EHR all of this information would be at the physician’s fingertips at the point of service. The physician would have to learn to use the computer as a physician extender. He must learn to treat the patient and not the computer. He must remember that a positive patient physician relationship has great therapeutic value. Personal contact and communication is vital to the therapeutic effect. My good friend, Dr. Richard Reece, a noted healthcare policy expert pointed out graphically this potential hazard in his excellent and funny blog post The Chart Before The Horse.

I believe with the ideal EHR both the patient’s and physician’s privacy can be protected. Actually, there should be a reward. The companies manufacturing the EHR should be able to provide the data to prove the increase in quality care automatically. I spoke about eliminating the barriers to improving medical care. The EHR can provide information to both the physician and the patient to increase the quality of care patients receive. Instruction to the patient can be printed in detail or sent to the patient online to their PHR.

There should be nothing about this transaction that gives patients the “willies”. It can only improve the delivery of care.

Stanley Feld M.D.,FACP,MACE

Some very good Electronic Health Records have been created. Last week, I received an excellent comment from Dan Schmidt, whose practice bought one of these very good EHRs. The views and pain he relates is exactly why quality Electronic Health Records have not gained traction with physicians. Dan has one of the best EHRs in Centricity by GE Healthcare. Actually Centricity is potentially an excellent product. GE Healthcare has invested heavily to solve the EHR problem. They manufacture and sell many products for the healthcare system. One problem they have is that the various products are not interconnected with their EHR.

Centricity is a relational data base that converts data points of information into word paragraphs. It provides a good looking electronic medical record, gets paper off the desktop and charts off the shelves. GE Healthcare is on the right track with Centricity. Centricity is capable of being what I believe is the Ideal Electronic Health Record. However, it misses on several counts. Why? Because they never asked the physician what his problems are. Again if they did ask some physicians, the physicians probably did not know what they needed.

Dan Schmidt M.D. expresses the problem beautifully.

“I believe the resistance in Primary Care to EHR is a reflection of the cynicism that has become pervasive.

So the problem, as you stated, really comes down to what does the physician expect from an EHR? There are lots of good products…We installed and ran Logician (Centricity) for 7 years in a primary care office. Paid for it ourselves, with no government support,,,,And now we have a huge data base that we don’t have the time or capital(manpower) or enthusiasm to institute quality improvement…”

My reaction to Dan’s comment is the following;

1. Dan knows what he needs. He has to have the important questions about the effectiveness and efficiency of his practice answered with his electronic health record. These questions are not answered because he does not have the time or capital to get them answered. The answers to his question have to be built into the EHR as he is creating the patient data at the point of service. The data analysis should be for his education. The data should not be for the insurance company, the government, or some malpractice lawyer to use against him.

The Institute of Medicine has said only 10% of physicians practice evidence based medicine. A relational data based information system can cue the physician to the practice of evidence based medicine. This system must be built into the EHR. The physician is then free to use his judgment. Centricity’s EHR has this capability. It is not available to Dan Schmidt because of the added cost of capital or time. If our goal is continuing quality improvement, physicians need the tools for continuing quality improvement. These tools have to be immune from liability in order for the physician to be interested in using an EHR.

2. The care to the patient has to be connected to the financial cost of the care as well as reimbursement for care. The cost of care includes pharmacy charges and hospital charges. The prices must be completely transparent to the physician. Most physicians have no idea of the cost of various drugs. If they knew they might order less costly drugs. Presently, Pharmacy Benefit Managers tell us what we can prescribe even if it is against our clinical judgment. This is not the way to generate trust between the physician and pharmacy. The physician should make the judgment with an understanding of the difference in cost to the patient. The EHR could provide that information with one click if programmed correctly.

These are two of many needs the physician has from an effective EHR. I will cover most of the other needs in future articles on EHR. These two additions would add value to the physicians practice and promote his understanding of his practice patterns. These additions should be used as a learning exercise by the physician. The data should not be used to criticize the physician and reduce his reimbursement. In other word he should not be penalized for his practice patterns. Most measurements of practice patterns have the wrong viewpoint. The point of view is to grade the physician’s practice pattern and not teach him how to change constructively. The measurements used to grade the physician presently are mostly the wrong measurements. It becomes easy to see the physician resistant to collecting data at a very steep price that is useless to his continuing . The physician does not have the time or the money to invest in an EHR that adds value to practice.

Once again, I thank Dan Schmidt for his truthful comment.

“The enthusiastic primary care docs are the ones doing lots of procedures(indicated?) and satisfying demand. You mentioned the 80% costs on chronic care. Most docs can name these 20% of their practice off the top of their heads(without an EHR) and their definition of improved care is to SEE THEM LESS.. Since the marginal improvement one obtains( 1-2 less hospital admissions, 1-2 less ER visits/ year) is such an incremental improvement, most primary care docs dismiss this success.
And it is hard to quantify.”

The above comment is also very important. It highlights the difficulty in Repairing of the Healthcare System. The only asset primary care physicians have to sell is time. Educating patients properly about their chronic disease is time intensive. The education time is either uncompensated or under compensated. Taking care of a patients with a chronic disease is also time intensive. The primary care physician’s time has been devalued. The only way for the primary care physician to improve time effectively is to not take care of the time intensive patients. The primary care physician passes these patients off to a specialist. The problem is the primary care physician is the contact physician for most of the patients with chronic diseases. There are not enough specialists to take care of all patients with chronic diseases. Therefore, they are not taken care of using evidence based medicine. If all physicians practiced evidence based medicine we could reduce the cost of care by at least 40% because 80% of the cost of care is spent on treating the complications of chronic disease. If we all practice evidence based medicine we could reduce the complications rate by at least 50%. Fifty percent of 80% is 40%. The total healthcare bill presently is $15 trillion per year. In an ideal world that would be $600 billion per year.

I hope some of the EHR companies are listening.

Next time I will define quality medical care, evidence based medicine and the role the EHR can play.

Stanley Feld M.D.,FACP,MACE

Paul Krugman (PK) wrote an article entitled “Is The Health Insurance Business A Racket?” Yes, literally — or so say two New York hospitals, which have filed a racketeering lawsuit against UnitedHealth Group and several of its affiliates.
I don’t know how the case will turn out. The two hospitals accuse UnitedHealth of operating a “rogue business plan” designed to avoid paying clients’ medical bills. For example, the suit alleges that patients were falsely told that Flushing Hospital was “not a network provider” so UnitedHealth did not pay the full network rate.

UnitedHealth has already settled charges of misleading clients about providers’ status brought by New York’s attorney general: the company paid restitution to plan members, while attributing the problem to computer errors.

But whatever happens in court, the lawsuit illustrates perfectly the dysfunctional nature of our health insurance system, a system in which resources that could have been used to pay for medical care is instead wasted in a zero-sum struggle over who ends up with the bill.”(PK)
Mr Krugman has said exactly what I have been saying in “Repairing the Healthcare System”. I believe this behavior occurs regularly with UnitedHealth.

I do not believe the people who run the insurance companies are bad people. It is simply that they will do many things to maximize their profit while destroying their cash cow, the healthcare system. Obviously, it is very short sighted on their part and very bad for the delivery of medical care. It seems they have no interest in improving the delivery of medical care.

“It is a fact that insurers spend a lot of money looking for ways to reject insurance claims. And health care providers, in turn, spend billions on “denial management,” employing specialist firms — including Ingenix, a subsidiary of, yes, UnitedHealth — to fight the insurers.”(PK)

You have heard all this before. However, I think it is important to repeat the obvious so people remain aware of what is going being done by facilitator stakeholders in the healthcare system.
One could say this is happening in every industry in America. They would be correct.

We can name many other industries where the same things are occurring. I have pointed out similar behavior of TXU and the Dirty Coal Burning Plants in Texas. Both industries seem to have a total disregard for the health and welfare of the common good as they price their way out of the market in order to maximize profits to the detriment of their customer, the American people. At the same time they are weakening the valuable American Healthcare System’s infrastructure. If the insurance industry and hospital were far sighted, we would not be in a healthcare delivery. Wouldn’t it be better for everyone to have all 46.7 million uninsured Americans’ have healthcare insurance in an environment that is competitive and provides constructive incentives to make the healthcare system better? Presently we have destructive incentives that make healthcare more costly and unaffordable.

“So it’s an arms race between insurers, who deploy software and manpower trying to find claims they can reject, and doctors and hospitals, who deploy their own forces in an effort to outsmart or challenge the insurers. And the cost of this arms race ends up being borne by the public, in the form of higher health care prices and higher insurance premiums.” (PK)

This arms race did not start yesterday. It started in the 1980’s when a distorted Medicare system caused industry to adjust to the price controls of the government. Everyone tried to figure out how to maximize profits at the expense of the patients, the healthcare system and the entire population. One compensating adjustment led to another distortion. The system became more and more dysfunctional.

“Of course, rejecting claims is a clumsy way to deny coverage. The best way for an insurer to avoid paying medical bills is to avoid selling insurance to people who really need it. An insurance company can accomplish this in two ways, through marketing that targets the healthy, and through underwriting: rejecting the sick or charging them higher premiums.”(PK)

Thus, the distortions that has lead to 46.7 million uninsured and an insurance industry that is paying its CEOs 2-10 million dollars a year, while the successful hospital CEO’s are busy justifying their $1 million plus salaries. The tragedy widens as Family Practitioners are barely making a living and the specialty of Internal Medicine is on the brink of extinction. The drivers of the healthcare system, the patients and the physicians, are in pain, while the life blood is being sucked out of the healthcare system by the insurance industry and hospitals.

“Which brings us back to the racketeering lawsuit brought against UnitedHealth by the hospitals. UnitedHealth is America’s second-largest health insurer, has a reputation for playing even rougher than its competitors.”(PK)

Even Mr. Krugman knows about UnitedHealth and the $1.8 billion payout to its former CEO. Ask any physician not working for UnitedHealth. They will tell you how rough UnitedHealth plays.

“ But the larger problem isn’t the behavior of any individual company. It’s the ugly incentives provided by a system in which giving care is punished, while denying it is rewarded.”(PK)
The same way People Power got the attention of the entire Texas population in the TXU case and TXU stock started to crash, People Power is the only thing that is going to turn this perverse Healthcare System mess around. You out there are the people!

Shel Isreal co author of Naked Conversations: How Blogs are Changing the Way Businesses Talk with Customers They say “we live in a time when most people don’t trust big companies. wrote a comment on January 20,2007 “Thanks for being so gracious. I enjoyed the conversation that it spawned between by email. repairing the medical system (Healthcare System) in America is a lofty goal and about 98 percent of the American people see the need. The rest work for insurance companies.”

I believe our democratic system works. The internet and blogosphere are democratizing organs. As soon as a critical mass of people are aware of the etiology of the problems in the healthcare system the Healthcare System will be Repaired with the consumer driving the change, not the government, or the insurance industry.

Stanley Feld M.D. FACP, MACE

Is the KKR and Texas Pacific Group leverage buyout good for North Texas? In order to make peace with public protest, the buyout team pledged not to ask for permits to build 11 Dirty Coal Burning Plants. They only want to build three (3). The permit to build the plant in Savoy, Texas will be withdrawn.

Late Saturday, February 24, 2007, KKR and Texas Pacific Group announced a $43 billion dollar leveraged buyout of TXU. The TXU board approved the buyout on Sunday.

How come so fast? According to the New York Times KKR, through Goldman Sachs, helped broker a peace with the environmental groups, and to get the environmental groups support for the transaction. If this is not a trick play on the part of TXU, KKR and Goldman Sachs, it represents a victory for the air quality in Texas. The new TXU is going to withdraw 7 of their 11 requests for permits for Dirty Coal Plants from the Texas Commission for Environmental Quality.

Grayson and Fannin counties just north of the Dallas Metroplex are the environmentally least polluted area of a very abused and polluted State of Texas.The building permit for the Valley Plant in Savoy, Texas has been promised not to be requested. This will not only keep Texomaland clean from coal pollution but save North Texas’ beautiful Lake Texoma from Mercury contamination. It will give Dallas and Ft. Worth a chance to achieve EPA attainment by 2010.

I have discussed the faulty Texas political system in the past. There seems to be an outright disregard for the health of Texans by our Governor Rick Perry and his probable unconstitutional support of the fast track permitting process.

Incidentally, I think Governor Rick Perry wants to run for Vice President in 2008 with the Republican candidate. I think the Republicans would be making a great mistake. He has, in my opinion, little common sense. He also says one thing and does another. He has ignored the will of the people on many occasions. The coal plant issue is only one of many faulty decisions that Governor Rick Perry has made.

There are many heroes in this effort to change TXU’s mind on the Dirty Coal Burning Plants. Listing the heroes would take pages. Only the uproar of the people (free speech), and the ability to educate the public saved the North Texas area from the health toxins Mercury, NOX, SO2, and Ozone and Particulate Matter. These toxins result in at least $34 billion of avoidable healthcare costs. Public protest was achieved through local meetings, internet connectivity, the blogosphere, and local and national media coverage.

It is my impression that the governor supported and fast tracked the process for less than noble reasons, The Texas legislature did not seem to want to get involved. Only through pressure by the uproar of the people did legislator timidly start signing on after only one state legislator made the protest proposal. Our national representatives did not say a word in defense of the people they represent and the people’s desire to have clean air in Texas.

I hope the lawyers that are working for CORE, SEED, and Environmental Defense are not blind sided by KKR. KKR is not the most benign leveraged buyout firm on the planet. I bet they bought TXU for a fraction of TXU’s real value just as they bought HCA for a fraction of its real value. In my opinion the reason KKR could buy TXU so cheaply is that public opinion made TXU public enemy number one. The public drove the price of the stock down making TXU a bargain at $43 billion dollars. I imagine the stock holders are relieved to get rid of their stock at the price KKR is paying.

I think we should not be thrilled that the State of Texas will only be getting 3 Dirty Coal Burning Plants. I think if there are going to be any Coal Plants, they should be Gasification Plants that reduce emissions drastically and are fitted with devices that also capture Carbon Dioxide. Carbon dioxide is the cause of global warming. It is a compound presently not required to be measured or regulated by EPA rules.

I have also noticed that in KKR and the new TXU’s discussions, the main immediate health dangers to the people of Texas are being ignored. The immediate danger is the health hazard of coal with Mercury emissions, Sulfur Dioxide, Nitrogen Oxides, Particulate Matter, and Ozone. The diseases resulting from Mercury are Autism, Attention Deficit Syndrome and Learning Disorder for Mercury at a societal cost of 100 billion dollars a year. Asthma, Chronic Obstructive Lung Disease (COPD), Heart disease for Nitrogen, Sulfur, and Ozone generate illness that cost the healthcare system $34 billion dollar a year aside from all human cost of morbidity and premature mortality. These costs are avoidable by not burning coal. Toxins not even mentioned or measured are uranium emission, dioxins and furans.

What am I nervous about? TXU will not longer be a public company. Therefore the public will not longer have any leverage over the stock price. There will be no chance for possible input by stockholders to the management. KKR and TXU can essentially do anything they want including raising electric prices or selling off our polluting electricity production on the national grid to others.

One friend called the leveraged buyout “eye wash.” It makes you feel better but does not cure the disease. It did not solve our problem of the disregard of our government for the public sentiment. Its’ lack of concern for the public’s health is astonishing to me. The present resolution of the immediate problem has simply made us feel better for the time being.

I am totally against government regulations and increased government bureaucracy. However, in order for the public to be protected, we might need electric power production to be regulated again in Texas, if TXU continues to abuse its’ power in the production of electricity.

We are all looking forward to the new TXU being the good neighbor they have claimed to be in the past. TXU investing in renewable energy for Texas would be a good start. We have plenty of wind and sun in Texas. They could also consider pricing it fairly if they want to earn the designation of a good neighbor.

My warning is watch out! This could be a trick play by TXU and KKR!

Stanley Feld M.D.,FACP,MACE

I thank my son Brad for writing about my post “Electronic Health Record Part 2”
in “Feld Thoughts.” I was pleased with the many comments that we both received. There are many smart people out there.

I think the difficulty in developing an EHR has been overstated. Most of the software pieces of the ideal electronic health record are currently available.

Few developers have asked the physicians what they need. Fewer developers understand why they encounter such massive physician resistance. Those who have tried to understand the resistance can not get a straight answer.

The reason is many physicians do not know what they need. They have little experience thinking about relational databases. They have difficulty understanding the potential to the increased efficiency of their daily workflow (effective relational databases) in the practice of clinical medicine. Most of the effective information technology in clinical practice has been in financial medical management. Financial outcomes have not been linked to medical practice outcomes in an understandable way.

EMR developers also have had difficulty getting the physician to sit down and listen to them. Physicians are very suspicious of data collection devices. Most of their experience has been with data collection that has been used against them by the facilitator stakeholders (the government, the insurance industry, and the hospitals) to penalize them or reduce fees.

I believe all the pieces of an ideal EHR are now. However, most of the pieces are stand alone silos and are not interconnected. The physician is offered an expensive and unaffordable product that seems to offer little added value to his practice except to eliminate paper. The value to the practice is not translated properly nor could they afford it if it was.

Brad Feld (my son) and my brother Charlie Feld have taught me a lot about information technology and relational databases. We have had many discussions about relational databases. I have studied its potential value to physician practices. In my opinion, few companies understand how the physician thinks and what his needs are. They do not know how to teach the physician to understand the value of an EHR to his practice.

I think the reason is that software developers are oriented toward the hospital as their customer and not the physician. Hospitals have money to spend on capital improvements. Physicians do not want to spend large amounts of money on anything, especially something that they perceive will add little value to their practice. In fact, the EMR might hurt their practice. They hear many horror stories from peers about worthless EMRs. Most effective EHRs are out of the price reach for the average physician or small physician groups. Physicians have heard and seen big organizations like Kaiser Foundation get fooled out of hundreds of millions of dollars. Many have had the same experience in their own hospital.

An Ideal Electronic Health Record can, I believe, be easily synthesized from the current technology in use by other businesses.

The EHR should be leased to the physician and the practice to make it affordable. The EHR should be sold at a penny a the click just as Mastercard’s system is sold to small businesses. The data can be stored on site or off site or both with stout privacy firewalls around each practice.

Many businesses rely on relational databases. Two simple examples are Amazon.com
and Netflix. Amazon tells me what books I would enjoy and Netflix tells me which movies I should order from my order history.

The airlines let me schedule a flight online. Southwest has my online ticket buying reduced to three clicks.

Wal-Mart buys store inventory based on sales. It automatically sets up delivery routes and schedules of thousands of products delivered to thousands of stores based on velocity of individual product sales.

Frito Lay builds potato chips and buys potato futures on the basis of historical experience and timely conditions such as social unrest or sporting events on television. If volume of sales drops in a city, Frito Lay automatically puts the potato chips on sale in that city.

E-trade, Schwab and others make trades online and adjudicate sales at the point of trade. I remember the days when stock prices were caulked up on a blackboard.

Almost every merchant uses Mastercard, Visa or American Express. They settle the price of purchases immediately. Mastercard even questions a charge that is too frequent. I was at a gas station and the pump was acting funny. I stopped pumping gas from that pump and reentered my credit card in another gas station. I was denied access. I also got an instant call from Mastercard asking me if I lost my card. The software picked up an unusual event in the use of the card.

Stores, restaurants and gasoline stations do not have a universal software system. They interface their different software systems with First Data’s system. First Data has been able to flatten out many interfaces so that there is universal processing at First Data’s end.

The banking industry has adopted online banking. I thought the personal banking would the last to adopt. The software company selling to the banking industry has made the interface easy for the personal banking customer. The pain of reconciling the bank statements is gone forever. Customer service encounters are down. Everyone seems happy. The banks net profits have increased and expenses have decreased because labor intensive tasks have decreased. The individual banking institutions do not own the software. They lease the software. They also pay by the click. The software people upgrade and maintain the software with all the appropriate backups and firewalls.

The same can be done with appropriate data based driven legacy medical information systems. However, many of the legacy medical clinics EMRs are not worth much. They are word processing systems and not data processing systems. Those systems will manage to get the paper out of charts and off the shelves. However, you can not learn anything from them to improve a clinical practice.

Most practice management systems have relational data base capability. You can figure out a percentage of Medicare population in the practice. You can also get the names of all the males over 55 years old with diabetes mellitus, impotence, and hypertension.
The EHR I am talking about is the next step. What have we, as physician, done to improve patient care? What has the medical outcome been? What is the price in medical services for the medical outcome? Are there any suggestions available using evidence based medicine for the physician to improve his outcome?

Remember, 80% of the cost of medical care is spent on the complications of chronic disease. How can we learn from the patients record how to reduce these complications without the threat of penalty to the physician.

What have I taught the patient? How much of what I taught him did he learn?
What is his adherence to prescribed medication?

How could a physician measure adherence to prescription with an EHR? The entire informational technology infrastructure is available. It can be automated. It is waiting for an entrepreneur to put it all together. When I give six months prescription, the patient only gets a thirty day supply from the pharmacy. This is a little scam the CVS’s of the world in conjunction with the insurance company exercise. Why? If your co-pay is $10 for a generic drug, CVS might charge a total price of $14. You paid $10 and your insurance company pays $4. For a six month supply your insurance company would pay $24 and you would pay $60. If they gave you the six month supply of medication I ordered you would pay a co-pay of $10 and the insurance company would pay $74. I would say that is a pretty neat drug benefit for the insurance company.

If I, as the prescribing physician, demanded that the CVSs of the world notify me by email each time the prescription is refilled, each notification could go directly into the patients EMR. On the patient’s next visit, I would know whether the patient refilled his medications appropriately. Patients have told me they refilled the medication when in fact the pharmacy had not seen the patient in the previous 4 months.

As an example such a patient would not be able to properly control his blood pressure. Uncontrolled blood pressure can lead to stroke or heart attack. Both are a complication of the underlying vascular disease that causes hypertension. Appropriate control of the blood pressure can reduce the possibility of stroke or heart attack by 50%.

Simply understanding and controlling compliance can save lives and reduce the cost of medical care. Can this process be automated with present day technology? Of course it can. It could help us be better physicians and give better service to our patients without it affecting our daily workflow.

I do not think it should take forever to have a universal web based EHR. It can be as rapid as CD’s replaced vinyl records. It takes an understanding of the physicians mentality, the physicians needs and the physician workflow. I will present many concrete examples of quality care improvement across all five parts of the EHR in the future.

Stanley Feld M.D.,FACP,MACE

An effective Electronic Health Record must consist of five components

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

In order to have a fully functional Electronic Health Record, all of the components of the EHR have to be integrated and in a relational data base format. This is the only way we are going to be able to determine if certain approaches to disease management in a clinical practice setting have positive medical outcomes and positive financial outcomes (reduce the cost of care for chronic disease).

The interoperability of all components of the EHR is the key to a successful EHR
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 properly. Without an interoperable EHR we can not evaluate medical outcomes and financial outcomes effectively. Therefore, interoperability is essential if the EHR is going to help reduce the cost of care.

I explained how you can create your own instant Personal Health Record last month. I believe it is important that we, as patients, assume this responsibility now. We need to start getting our physicians used to our needs.

Every examination and every test done on you by your physician or a physician you are referred to belong to you. You or your insurance company paid for the test or the examination. You paid the physician to interpret the test. The test results should be in your possession. You could move to another city, change physicians, your physician could retire, or close his practice. If so, an important piece of your medical data could be lost forever. It should be your responsibility to maintain your data base.

Ideally, if your physician had an EMR he could electronically transfer your test result data and his interpretation to your PMR. He then has a copy and you have a copy. Both copies could be web based and well encrypted for privacy.

The Continuity of Care (CCR) part of the EHR should also be interconnected with both the EMR and PMR. The CCR should be the core data set of the patients disease record. In should contain a summary of the patient’s medical problems, treatment, medications, response to medications, and issues of care(compliance, adverse reaction to medications and treatment).

The CCR is the perfect place for the interactive section of the medical record. It can be used to teach the patients how become a “Professor of their Chronic Disease.”

If we think about Diabetes Mellitus as the chronic disease in point, the CCR should become a customized Diabetic Education Center. A newly diagnosed diabetic should have formal teaching about Diabetes in a Diabetes Education Center. After those initial encounters, depending on the patient’s learning skills, modules can be customized online by the physician to improve that patient’s skills in self-management. (See AACE guideline for Intensive Self Management of Diabetes Mellitus: A System of Intensive Diabetes Self Management. Obviously, this effort should not be uncompensated or undercompensated as it is presently. With an MSA the patient would be making the decision and not the insurance company who is interested in paying as little short term money as possible despite the long term benefit.

The continuing education piece of the CCR could feed back information interactively to both the physician and patient on the course of the chronic disease. It could continually monitor the patient’s response to treatment and changes in the self-management of the illness. The CCR could be customized with suggestions for the patient on how to improve self-management of the chronic disease to increase the quality of care and decrease the complication rate. Tim Wolters of Collective Intellect is trying to figure this out.

The immediate response of physicians is that such a system would cost too much. They also think integrated systems like this could never become universal in our chaotic healthcare system.

I think it could become universal with the proper visionary intervention and leadership. Rather than selling a complete software system to physicians, a clever software company would simply have the complete EHR in a web based format on the internet. Instead of charging the physician fifty (50) to eighty (80) thousand dollars per physician, the physician and the patient would pay to use the system by the click. The physician would not bear the burden of the initial capital expenditure and ongoing support costs of the EHR. He would have the ideal EHR with free upgrades.

Patients would not feel a burden of cost to access their record either because they would be billed by the click. The advantage would be an integrated communication system. The system would have the advantage of being data formatted, interconnected and relational with medical and financial outcomes.

PMR and EMR must be synchronized to other components of the EHR. A vital connection would be with the Financial Management Record. There is no reason in a price transparent, consumer driven healthcare system where the consumers own their healthcare dollar that the consumer can not make the instant decision about the charges. The insurance claim is generated at point of service and integrated with the service. The patient makes the decision to pay the bill by credit card, just as the consumer does in during a typical store purchase. The bill is adjudicated instantly by credit card and deducted from the patient’s Medical Saving Trust Account.

The physician’s office has saved the expense of filing a claim, waiting for the claim to get adjudicated and then receiving payment three months later. The new electronic system (EHR) eliminates the $150 billon dollars of administrative waste in the healthcare system.

Why hasn’t someone in the insurance industry thought of this? Maybe they make too much money from being inefficient and having administrative waste.
Paul Krugman (New York Times February 16,2007) says it beautifully in the article entitled “ The Health Care Racket”

I have pointed out previously why hospitals do not want to change the faulty DRG system. It could be Insurance companies do not want to eliminate administrative waste because they and their subsidiaries’ profit from this waste.

Physicians who bought ineffective EMR’s might not want to put them aside for an effective system However, a powerful incentive could be instant adjudication of payment of claims by the patient.
It is going to take leadership and innovation plus the demand from the people, to create a much need paradigm shift from the way the healthcare system does business presently.

Stanley Feld M.D.,FACP,MACE

The $2.1 billion is at the low end of a 1000 bed hospital’s total revenue. Bed fees are even higher than the $12,000/day average for cardiac patients with complications. This is called DRG creep. The hospitals have also managed to get the patients out of the hospital under the DRG cap. If not, they seem to find a way to extend the DRG cap. The cap means that certain illnesses are paid a flat fee and given number of hospital days. Let us say a DRG for an illness payment is $24,000 ($6,000/day for 4 day hospital stay). If the patient is in the hospital for six days the hospital gets the same $24,000. If the patient is in for three days they get $24,000. You can see why the hospital’s motto is get them out fast.

We are unable to know the hospital’s actual overhead. If we did, we could to find out what the hospital’s actual costs are. We could then calculate the hospital’s profit. These numbers are totally opaque.

Most hospitals are non profit hospitals. They can not post a profit at the end of the year? Therefore, they have to pour the extra money into something. Executive salaries and capital expenditures are a prime avenue for getting rid of their profit. A key question is how is the hospital’s overhead calculated? Maybe reducing costs to the consumer would be a good idea?
If a hospital makes capital expenditures with the capital they have to spend each year they receive added cash incentives. If a hospital has a house staff or nursing school there is sizable bonus received from Medicare for the professional training programs.

I received this comment from a knowledgeable follower of my blog

“Stan

Richard Dickey M.D. ,FACE”

If you would suddenly became ill and have to go to an emergency room, because you need help immediately, you can not shop for a hospital on the internet. You are stuck. Shouldn’t there be some rules that reflect the cost and value of the hospital service? If your life is saved, the fee charged is priceless if you had some way of paying for it.

The solution is not price controls or a single party payer. The solution is price transparency, and the creation of a price competitive environment among hospitals.

President Bush’s approval rating is at an all time low because of the Iraq war. However, his medical advisors understand the healthcare systems problems. He has called for price transparency. Congress, under the influence of vested interests, stopped him. He called for DRG reform on the basis of hospitals’ cost and not charges. Again congressional outcry influenced by vested interest stopped the process. I have a feeling Mark McClellan M.D., Director of CMS, quit because of the delay in DRG reform.

President Bush has been able to get through some insurance reform. The deductible limit on a Health Savings Accounts have been raised for an individual is now $5250 and 10,500 for a family. However, the HSAs are constructed in favor of the insurance industry and not the patient. They still do not have a community rating system in place. The insurance industry fought with 4 years of lobbying to stop a Medical Saving Account in favor of the patient.

This year President Bush proposed tax deduction of up to $15,000 per family to by insurance. Yesterday he told hospitals not to press their luck about prices and charges.

I know the President and his people know all the issues necessary for true reform and the repair of the healthcare system. They simply can not accomplish true reform piecemeal. The piecemeal approach to the entire needs for effective healthcare reform to occur is inot understandable to the goal of reform to the public, media or congress. Piecemeal reform will also get distorted by the vested interests (facilitator stakeholders) during the legislative delays.

Medicare has not hesitated to reduce physician fees. They will be reduced 5% again this year. Medicare is presently regulating the price it is paying the physicians. The government’s tactic seems to be to beat up the guy you can beat up the easiest.

Congressman Pete Stark has said all physicians game the system. They have to be stopped. Congressman Stark’s view is far from correct. However, if you instinctively know you have a product or service that is needed, and other stakeholders are taking undo advantage of a dysfunctional system, some feel they might as well try to get their share.

However, when Mark McCellan M.D. discovered that 90% of the healthcare dollar was spent on the complications of chronic disease. His goal was to improve chronic disease management to reduce complications.

The government declared in the Federal Register it was going to reduce the payment for Bone Mineral Density by 70% over the next four years. The medical profession made a feeble attempt to stop the reduction. A Bone Mineral Density can diagnose early osteoporosis. Early treatment can prevent future osteoporotic fractures.

When the government tried to change the DRG system to reflect the actual hospital cost of service as opposed to charges, Congressman came out the woodwork to delay and stop the process.

How come? The political system has nothing to do with common sense and logic. It is driven by the most effective vested interests.

Who should have the most important vested interests? We are supposed to have a government run by the people for the people and not the best lobbying group. People need to step up and speak out!! Eventually, the wisdom of the democratic process and the peoples’ interest will prevail. We do not have the time to wait. We must speak up now!

Stanley Feld M.D.,FACP,MACE

Val Jones M.D. Senior Medical Director of Revolution Health in her Voice of Reason Blog post entitled “Hospital Adminstrators’ Salaries Draining The System” was more vitriolic than I was about Paul Levy’s defense of his one million dollar plus Hospital administrator CEO salary.

In her post she said
“Well, this conversation from the blogosphere gets my blood boiling, I can tell you! In a recent blog post about the ugly under belly of hospitals, I discussed how administrator salaries decrease hospital resources. Dr. Stanley Feld’s excellent blog post digs even deeper:”

In her post “Why Hospitals Are So Ugly” she said, “So one day I called the chair of the department of interior design at Parsons School of Design and asked whether she might send her students to my hospital to consider how to improve our situation.”
“I found out much later that our acting CEO was making about ½ million dollars per year in salary at the time. All the while the poor patients had to recover in a grim void of sensory stimulation.
Several months later the Parsons students made a presentation to our hospital’s executive team, and this was met with great enthusiasm. We all thought that we were on the verge of an exciting breakthrough for patient wellness. But alas, in the end not a single design suggestion was implemented as our administrators told us that there was no money available for environmental improvements.”
There is ugliness in hospitals – and it runs deeper than the white walls. As with many sectors, money is the deciding factor regarding whether or not something gets done. I think that hospitals should take a hard look at their white walls, and the white linings of their executive pockets and ask themselves whom they were built to serve.”

Many physicians have experienced false hope and false promises from hospital administrators. Val Jones M.D. hit the nail on the head. It is all about money! A big part of the healthcare system’s dysfunction “runs deeper than the white walls” in the hospitals. The healthcare system’s dysfunction originates in the board room of administrative meetings, the synergism of hospitals with the insurance industry(see Dr. David Westbrock’s comment at the bottom of the link)
and a faulty DRG system.

A faulty DRG system that hospital administrators have learned to exploit over the past 23 years.
The patients are simply pawns in the money game. Paul Levy gets an incentive bonus on revenue generated from this faulty system. There are many ways to optimize DRG payments from private insurance, Medicare and Mediciad. All you have to do is hire the right consultant to teach you how to do it.

The loser is the patient. The biggest losers is the patient without health insurance because he is responsible for the retail price and society as a whole.

DRG payments for Massachusetts are totally opaque. The only state I could find that publishes DRG charges was Wisconsin. It is fascinating to explore the hospital charges for various illnesses. I picked a hospital in Milwaukee and choose coronary angiography and cardiac bypass surgery as examples of charges. The report also presents payments from the insurance industry, Medicare and Medicaid. These charges are hospital charges and do not reflect hospital costs.

It is true sticker shock. It is an explicit examples of how hospitals charge and what they get paid. The hospitals collect 71% from private insurance, 39% from Medicare and 27% from Medicaid. I was told in a personal communication that a hospital can make a very nice profit with Medicaid payment for Obstetrical care service if efficient care us delivered. A bed generating $12,000 a day on average, is not a bad business.

The hospital charges for sub-specialty procedures are even more. Disease complications (risk weighting) increases charges further.

Let us assume at the low end the average payment is $6,000 a day per bed according to the Wisconsin DRG price information. The bed revenue in 365 days is $2,190,000 per year. A 1,000 bed hospital would generate revenue of $2,190,000,000 (2.19 billion dollars) a year. What is the hospital’s real overhead? Just try to find out! Have you ever wondered how almost every hospital in the country can afford to expand? Does Paul Levy deserve a performance bonus? How much are other secondary administrators earning? What kind of incentive bonuses are they getting? How does that add value to the patient-physician relationship? We have a big problem!

I will discuss one piece of the solution next time.

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