Stanley Feld M.D.,FACP,MACE

Paul Levy CEO of Beth Israel Hospital writes a blog called” Running a Hospital”. He has tried to justify his salary after the Boston Globe published his salary of over 1 million dollars per year.

Mr. Levy’s statement is a worthwhile read. He is justifying his salary on the basis of revenue generated, and donations received. He is also comparing his job to the jobs of CEOs of large corporations that make more than he does. His justification a well articulated as are most of the comments both positive and negative.

It is bizarre to me to read this kind of thinking at a time when most agree the healthcare system is broken.

Some feel it is about to implode. Paul Levy has figured out how to have his institution survive in a broken healthcare system. I cannot understand how he would have the guts to brag about how much he is worth rather than do something to help fix the broken system. He could hire more nurses. He could provide preventative management care to the community to decrease the incidence of the complications of chronic disease.

Remember, the complications of chronic disease cost the healthcare system 80% of the healthcare dollars spent. Effective disease management using evidence based medicine can decrease the complication rate by at least 50%. The net savings to the healthcare system would be 40% or more.

What about the patients who can not afford insurance? What about the opacity of hospital prices charged for services? Remember Denise’s letter to Kinky Friedman and her problem with hospital pricing? What about the overcharging of hospitals through a faulty DRG system? What about the constant shortage of nurses because of low salaries?

What about the continuing decreases in payments to physicians by Medicare and the insurance industry?

Linda Halderman M.D. wrote an essay entitled “How Much is Your Doctor Worth?”. It is also worth reading. The subtitle should be, “How Much is Your Doctor paid?” The answer after the long essay is $59.50 for this complicated office visit. Dr. Halderman would only have to see 168,067 patients in one year or 744 patients a day to generate a gross revenue of $1,000,000 before expenses.

What is more valuable to the healthcare system? A CEO’s salary based on revenue generated incentives and fund raising or good quality medical care?

Family Practitioners and Internists are struggling to survive.

Some have experienced that their overhead is greater than their revenue. Some have had to hold two jobs. The American College of Physicians published a White Paper declaring that the specialty of Internal Medicine is in grave danger. Patients cannot afford their medication. If they do not take their medication they will accumulate more and more complications of chronic diseases. Complications of chronic disease are good for the hospitals’ bottom line. This should result in more revenue for Paul Levy’s hospital. By his reasoning he will be entitled to a greater performance bonus at the end of the year.

Dr. Donald Seldin, the legendary Chief of Internal Medicine at University of Texas, Southwestern Medical School imbedded in our brains, when we were residents of Internal Medicine, that the practice of medicine is a princely profession. We, as physicians, have the privilege of caring for the sick. Hospital administrators, as facilitator stakeholders, should feel the same obligation. They have an obligation to the community to make medical care available and affordable. The mission should not be to enhance the hospitals’ bottom line in order to increase the performance bonus of the CEO.

Remember hospitals such as Beth Israel Hospital in Boston are tax exempt community hospitals because they have this community obligation. These tax subsides and others tax subsides are opaque to the public. However, the public pays for these subsides. They contribute to the hospitals bottom line and Mr. Levy’s bonus.

Kevin,MD Medical webblog (A wonderful medical blog) picked up Paul Levy’s blog. Mary Lu, a fellow hospital administrator, commented in Kevin’s blog a sentiment expressed many people.

“Kevin, this guy gets the brass ones award for being so forthcoming– It will be interesting to follow how this affects his perception of himself. As a fellow administrator, who is paid a hell of a lot less, I can only wonder what in the hell possessed him to write this. But… it’s going to be interesting!
# posted by Mary Lu : 6:11 AM”

I think you can start seeing what medical care system, the healthcare system, and the American public is up against. Single party payer will simply result in more abuse to healthcare delivery. l

The solution would be easy if we can force the political system to respond with common sense. The logical response does not happen often in our political system.

Patients have to take charge of the system now!! The patients must control their healthcare dollar with the Ideal Medical Saving Account System. I believe this is the only way we can set up a price competitive system.

The politicians will not do it on their own. The political system can do it with pressure from you, the people, on your State Governments.

We have a lot of work to do. First, we must understand the issues.

Stanley Feld M.D., FACP, MACE

The solution should be pretty clear to all following my blog. I advocate the American way! I believe a consumer market driven system with government making rules for the benefit of all members of the society. When one stakeholder takes advantage of another stakeholder to the harm of the other stakeholder the government has to intercede.

Richard Swersey Columbia College Class of 1959 has a college degree in the ability to think! He also has a post graduate mining degree and masters of business administration. He wrote “You referenced Adam Smith in your blog on dirty coal plants. People need to be reminded that: (1) there is a large section of “Wealth of Nations” entitled “The Role of the Sovereign”. Even Adam Smith recognized that the market can’t do everything; and (2) there has never been a time in recorded history where commerce (or markets, or industry) was totally free of government intervention.”

I made the same point in the blog on the TXU proposed dirty coal plants. Adam Smith’s treatise also applies to the healthcare system. The function of government is to promote civility (civil right) for the benefit of all and not to build bureaucracies that can not possibly work effectively.

Dick is absolutely correct. The function of government in a democracy should be to function for the people by the people. The operative words are for the people and not to the disadvantage of the people.

Entrepreneurship and obtaining a competitive advantage is the engine that drives innovation in America. Our problem in medicine right now is some the facilitator stakeholders have large vested interests they need to protect. They are very busy protecting their vested interest by various political means. Unfortunately government is not acting for the benefit of the people. The advantaged stakeholders are so short sighted that they can not see that the system they are protecting is falling apart right in front of their eyes. In fact, it is about to blow up. We, the primary stakeholders (patients and physicians) can not see what does not hurt us. We are waiting for the Katrina effect. The mentality of what we can not see can not hurt us has to stop. We have to act know and demand change.

In my view price transparency and the consumer (patient) being in control of their own healthcare dollar can go a long way to transform medical services into a competitive market place.
Some of the insurance companies are talking a good game. Aetna has feigned price transparency in Cincinnati. They published only the price of the top thirty procedures for customers that bought HSAs. This is good start but never expanded to my knowledge. I called this blog Another Smoke Screen.

Wal-Mart made an innovative advance with its generic drug initiative. They are charging $4 for a thirty day supply of generic drugs. They have 340 drugs in the formulary. Physicians feel comfortable using some generic drugs. They also want to help their patients. Patients can also demand generic drugs. Most physicians will use generic drugs if there is not a clear cut difference between the generic and brand name medication.

Wal-Mart can not keep the drugs in stock. They also can not keep people out of the store. Wal-Mart is not losing money on the drugs either. The result will be an increase in net profit to Wal-Mart and a consumer driven market benefit for the patient. It will also force brand name drugs to come down in price. Wal-Mat’s initiative will created a clear market driven economy for buying drugs.

Who needs Medicare Part D and its $10 co pay along with its ominous $2200 doughnut? Wal-Mart is also setting up competitive price wars among CVS, Walgreens Rite Aid. Wal-Mart has good chance of winning because it has the mentality to engage in these kinds of innovative programs. The CVSs will get there as it works its way through their hierarchical bureaucracy. The end result will probably be too little too late for CVS.

The most of the uninsured who could buy insurance have had no choice but to not buy insurance.
They have chosen take their chances. When they get sick someone has to pay or not get paid. This is the point. It gets painful and costly for all the stakeholders. The Canadian model of Universal Health Care with a single party payer does not work. The costs rise, access to care is restricted and patients die.

The main question is how do we fix the problems. We have to exercise some common sense. We need to be equitable. The vested interest empires (facilitator stakeholders) have to start to understand that our most precious possession is our health and not their profit. A healthy nation is a strong the nation. They have to stop fight the Repair of the Healthcare System.

Price transparency, reform DRG on cost and not charges are very important. We must stop the bonus to hospitals or insurance companies for supposed cost overruns at the end of the year. We must provide incentive for disease management training to all patients with chronic disease. We must make the patient responsible for their healthcare and healthcare dollar in a price transparent environment. We must motivate the patient to care for their chronic disease by rewarding prevention of complications of disease.

We must eliminate hospital and insurance company administrative waste. We must neutralize defensive medical practice by malpractice reform. We must revolutionize the adjudication of claims system to a system of instant payment.

We must provide and institute an EHR universally that can measure outcomes. The outcomes we must measure are the medical outcomes. The medical outcomes must be relational to the financial outcomes and patient and physician input as to the value of the outcome.

We need to start getting serious about all of these issues in unison. We have to concentrate on the cost of complications of chronic disease. We must create financial incentives for preventative services. We have to teach the patient the “Professor of their Chronic Disease”.
http://stanleyfeldmdmace.typepad.com/repairing_the_healthcare_/2006/06/do_complication.html

We must motivate the patients to be responsible for their chronic care. If they are not they will have a financial loss as well as a medical loss. We must put the patients in control of their healthcare dollar. I believe if we did all of this our healthcare system would not be in trouble. All of this can be accomplished with the Ideal Medical Savings Account. The structure of the current HSA system will not accomplish all of these key initiatives

If the government wanted to subsidize something it would be the purchase of the ideal medical savings accounts for all the uninsured who could not afford to buy insurance. This would eliminate all the waste in Medicaid. The concept of universal healthcare with the government as a single party payer is a sham because it does not address any of these important initiatives.

Stanley Feld M.D.,FACP,MACE

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Stanley Feld M.D.,FACP,MACE

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

Minnesota hospitals: Rising red ink

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

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

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

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

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

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

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

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

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

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

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

Stanley Feld M.D.,FACP,MACE

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

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

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

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

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


Does everyone understand the above??

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

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

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

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

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

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

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

Stanley Feld M.D.,FACP,MACE

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

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

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

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

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

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

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

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

Thank you Brad

Stanley Feld MD,FACP,MACE

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

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

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

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

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

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

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

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

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

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

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

Stanley Feld M.D.,FACP, MACE

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

I will continue to expand on the ideal EHR.

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

Stanley Feld MD, FACP, MACE

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

“Kaiser: Critical Need To Cut Rising Costs”

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

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

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

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

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

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

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

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

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

There Are Many Types Of Electronic Records In Use Presently.

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

Somehow all of these electronic records have to be combined.

Interoperability Is The Key To Any Successful EHR

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

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

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

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

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

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

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

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