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The Shovel Ready EMR Project?

May 22, 2015

inDisinformation and the healthcare system, EMR

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Stanley Feld M.D.,FACP,MACE

The Health Information Technology for Economic and Clinical Health (HITECH) Act passed in 2009 directed 5 % of the $800 billion dollar economic stimulus package towards digitizing medical records.

This was considered one of President Obama’s shovel ready projects. This project has lots of problems and was much less than shovel ready.

It was George W. Bush, not Obama, who started the project to digitize medical records. EMRs make sense if they are directed toward improving patient care.

President Obama funded the project with his shovel ready economic stimulus package in 2009. Physicians dislike the project. Patients find little value in the project.

It is estimated that in five years 50 times more health information will be generated and digitized than today. Diagnoses, treatments, DNA, medical images and vital signs already are being analyzed and stored.

One large problem is Americans don’t own their own healthcare information.

In its present form patients find little useful information in the EMRs. Many of the EMRs do not fit the Obama administration’s criteria of meaningful use EMRs. Medical practices will experience a penalty this year.

Government punishment hardly ever works. Government providing for innovative opportunities works.

The government and the insurance industry own the information.

The big data is derived from meaningful use EMRs. The government is only interested in evaluating the quality of physicians’ care. The government would like to decide on the reimbursement of that care.

The EMR has not added value to patient care because physicians have to spend too much time concentrating on filling in required documentation. Much of the information is worthless because they cut and paste template reports that are required documentation for the government to judge. The medical record is cluttered with information that is not useful.

The cost is physicians do not have time to relate to patients.

Michael F. Raab, M.D.Sanibel, Fla writes in the WSJ

“I recently received 147 pages of EMR which took me 30 minutes to review. I only found three lines that added new information.”

HIPAA (Health Insurance Portability and Accountability Act) requires hospitals, physicians, labs, pharmacies and other “covered entities” as well as the health plans and their “business associates” (for example, an information-technology vendor) to protect how your data. This rule applies only to paper record. It does not apply to digital records.

“Most EMRs aren’t covered by HIPAA at all, and providers and vendors can do whatever they want with your information.”

Digital records are vulnerable to hackers. Health records were stolen from nearly 80 million Anthem health-plan members. The façade of privacy has been exposed.

Electronic medical records companies, and hospitals and health systems that own physician practices own the patients’ digitized healthcare records.

These entities have withheld health information from patients in order to gain an edge over competitors. It becomes difficult for patients to switch to other healthcare plans or providers without their records.

Patients are entitled to their records but they must get past vendor delays.

There is great financial value of patients’ data beyond competitive advantages to these providers. The value is in marketing research for specific demographics. The revenue comes from using health information for drug research, targeted marketing and other efforts.

Many big data companies are investing heavily to own a piece of the multi-billion-dollar monetization of health information.

“These companies know that whoever controls health information will dominate the health-care marketplace and its vast profit pool.”

Congress has been slow to fix these problems. It needs to update health-information policy and privacy rules.

These are the four most important rules that Dr.David Brailer (the former national health information technology coordinator in the Department of Health and Human Services (2004-06)has outlined.

"1. Individuals should have unqualified ownership of their health information. Every person should be able to access his information whenever he wants, without blocking or delay.

1a. Health information should automatically follow patients wherever they get treated, unless they don’t want that to happen.

1b. Patients should be able to control which people and organizations are allowed to see their information, and whether those organizations can retain that information.

2. Individuals should be able to designate an intermediary to manage their information on their behalf. Many people would not want to handle their health information, so an “infomediary” could assist them and ensure that their information is used to advance their health status.

2a. Intermediaries could be a spouse, a hospital, a health plan, a pharmacy or even a tech company like Google, SalesForce or Yahoo.

3. Standards for security protection should be raised so that information is protected wherever it flows.

3a. A secure medical Internet—encrypted data lines that are walled off from hackers and other threats—is needed to protect the perpetual movement of information among hospitals, physicians and other legitimate data holders.

4. Every “covered entity” that touches health data, including every app, should follow the same rules."

Congress must act now!

The goal of the EMR was to have computers that could talk to each other for instant availability of patients’ medical information to enhance care and decrease retesting.

The availability of the $30 billion dollar Obama stimulus and the lack of consumer control has led to an evolving inefficient bureaucracy and rules and regulations that have created pain for the two most important stakeholders, patients and physicians.

The EMR project was not shovel ready as President Obama promised. It has turned out to be a waste of money. Instead of improving patient care it is hurting patient care.

An effective healthcare system would provide consumers with ownership of their healthcare data, their healthcare dollars and a desire to be responsible for their health.

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

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Pure Genius Or Pure Stupidity?

October 16, 2013

inInnovations in Healthcare, Medicine: Healthcare System, Politicians,Healthcare and Vested Interests, Stakeholder Mistrust

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Stanley Feld M.D.,FACP,MACE

President
Obama’s actions as leader of this country have been either pure genius or purely
stupid.

I think it
is pure genius. He promised Americans he was going to fundamentally change
America. He has!

Americans
have been under stress during the last few weeks. First it was the government
shutdown. Now it is the nation going into default. It is common knowledge the
shutdown and default is political theater.

President
Obama has run circles around Republican in the game of political theater.

The
traditional media has ignored the underlying causes of America’s problems.

We are increasing
debt to the point of unaffordability. The only way out is to increase taxes
further or decrease government spending while lowering taxes.

Increased
deficits are not good. Deficit increases devalues our currency. America’s currency
has already been devalued by the Federal Reserve increase in printing money.

Increasing
taxes leads to decreased jobs creation. Decreased employment leads to decreased
discretionary spending. The result is decreased economic growth.

Rather
than trying to decrease spending rationally by increasing government
efficiency, President Obama has closed down silly things to make it most painful
and noticeable to the public. These noticeable services have little overhead.
These closures are not an example of reducing inefficient spending.

In the
meanwhile his administration has spent over $600 million dollars for a health
insurance exchange software program. The program is poorly designed and does
not have an integrated back end.

Even if
the software was great, the cost of healthcare insurance through the exchanges
is increased and out of reach of the individual buyers.

The cost of insurance is cheap for the poor who
qualify for government subsidies. The poor will receive a tax credit which will
be credited to the insurance company whose policy the poor person buys.

The math
is grotesque. If a healthcare policy costs $10,000 and a patient makes $30,000
dollars a year, he pays only 2% of his net income for the policy or $600 per
year. The taxpayer pays $9,400 a year for that policy.

This is
an example of hidden “redistribution of
wealth” and another entitlement.

The
Obama administration has waived the verification requirement for receiving a health
insurance exchange subsidy. Verification of need does not have to be fulfilled
by the health insurance exchanges. Anyone can lie and receive a subsidy to
purchase healthcare insurance threw an exchange.

Another
big mistake was the design of the roll out to promote electronic medical
records. After 4 years only 11% of these records are functional. Physicians have
spent money for EMRs they could not afford. Hospital systems spent money they
could not afford. The government wasted $30 -60 million dollars of taxpayers
money in the unsuccessful effort to implement EMRs.

America
is a long way away from being computerized with a functional EMR.

Accountable
care organizations (ACO) are another important cog in Obamacare’s success or
failure. The administration brags about the fact that 250 ACOs are in
development.

There
are over 5,000 ACOs that need to be developed. A premier organization such as
the Cleveland Clinic had to drop out of the program because of the cost to the
institution. The Mayo Clinic refused to participate.

At the
same time ACO’s are turning out not to be cheaper or have better outcomes than
traditional medical care.

ACOs
were supposed to improve quality. ACOs were supposed to be a free market
solution to the dysfunctional healthcare system.

The
administration has been bragging about the greatness of the VA system. The
bragging stopped when the system’s poor quality of care was exposed. Veterans
are receiving poor treatment.

Everyone
would certainly have to admit Obamacare has been disruptive to the delivery of healthcare
in America.

The
months of healthcare insurance open enrollment for people is starting. People
are starting to see massive increases in their healthcare premiums. In order to
avoid these premium increases and the Obamacare penalties, large organization
such as Home Depot are hiring only part time workers.

The
Obama administration has developed a low cost insurance plan for the McDonalds
of the world. These health insurance policies cost little a cover less.

President
Obama has also provided waivers for congress and its employees. He is at
present trying to sneak in waivers from Obamacare to unions.

“First, there was the delay of
Obamacare’s Medicare cuts until
after the election. Then there was the delay of the law’s employer mandate. Then there was the announcement,
buried in the Federal Register, that the administration would delay
enforcement of a number of key eligibility requirements for the law’s health
insurance subsidies, relying on the “honor system” instead. Now comes word that another
costly provision of the health law—its caps on out-of-pocket insurance
costs—will be delayed for one more year.”

The
Obama administration has issued a blizzard of mandates and regulations. These
regulations have increased the cost of health insurance.

The caps
on out-of-pocket insurance costs, such as co-pays and deductibles have not been
publicized. On January 1, 2014, deductibles were supposed to be limited to $2,000 per year for
individual plans, and $4,000 per year for family plans.

In
February 2014, the Department of Labor published a little-noticed rule delaying
the cap until 2015. The costs of these deductible limits were already built into
the 2014 healthcare insurance premiums and were not removed.

The
government did nothing to reduce the increased healthcare premiums after the
limits did not apply.

“Federal officials said that many insurers and
employers needed more time to comply because they used separate companies to
help administer major medical coverage and drug benefits, with separate limits
on out-of-pocket costs. In many cases, the companies have separate computer
systems that cannot communicate with one another.”

“We
had to balance the interests of consumers with the concerns of health plan
sponsors and carriers.”

How is it in the consumers’ interests to pay far
more for health insurance than they do already?

I have a theory.

President Obama’s ultimate goal is to have a complete
government takeover of the healthcare system. A takeover the government cannot
afford.

He figures by creating as much chaos as possible
now in the “not so free market healthcare system”, he can declare the free
market healthcare system has failed.

There will be a resulting public outcry for the
government to help and take over the system.

The takeover will be with a single party payer
system.

What are the chances a government takeover will
result in an efficient, cost effective system that will provide access to care
without rationing of care while being affordable?

With all the delays, exemptions and regulations,
it looks as if Obamacare is destined to fail. Obamacare is going to be
impossible to execute effectively.

Obamacare’s ultimate failure is playing right
into President Obama’s ideological goal
of a single party payer system.

President Obama is not stupid. He is a genius.

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

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The False Promise of Electronic Medical Records (EMR)

April 24, 2013

inDisinformation and the healthcare system, Information Technology in Healthcare, Medicine: Healthcare System

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Stanley Feld M.D. FACP,MACE

The
promise of the Electronic Medical Record (EMR) is fading for physicians and
patients. The EMR was supposed to reduce the cost of medical care, improve
quality of care, improve physician communications, reduce duplicate testing and
improve efficiency of care.

I
believe EMRs can accomplish all of the above goals but not with their present
rollout format.

In
2009 President Obama declared that EMRs,

“would
save some $80 billion a year, safeguard against medical errors, reduce
malpractice lawsuits, and greatly facilitate both preventive care and ongoing
therapy of the chronically ill.”

President Obama's estimate is a little higher than that of the Rand Corp. study on the same issue.

EMR’s have
not accomplished its goals. EMRs have been a money-loser for most physicians.

I
predicted that fully functioning EMRs were too expensive for most practicing
physicians. In addition to the initial expense there are very high maintenance costs.

EMRs
bought by physicians and hospital systems in the past are not fully functional.
Less than 20% of hospital systems and
physicians practices that have fully functional EMRs

Physicians
and hospital systems that already have EMRs will have to purchase new fully
functional EMRs.

Physicians
historically know that all data collected, whether accurate or not, has been
used against them in the past.

They
are hesitant to provide more data at their own expense that compromise the
privacy of their patients and potentially harm their own reputation.

Physicians
would be happy to participate in EMR implementation if the EMR improved their
ability to serve their patients without a potential penalty.

It
is clear the government and healthcare insurance industry want to control the
healthcare system. The stakeholder who controls the data controls the
healthcare system.

A
recent survey from
forty-nine community practices in a large EMR pilot study by the Massachusetts
eHealth Collaborative studied the projected five-year financial returns on
investment to physicians’ practices. It was published in Health Affairs.

The
survey concluded,

"We found that the average
physician would lose $43,743 over five years; just 27 percent of practices
would have achieved a positive return on investment; and only an additional
14 percent of practices would have come out ahead had they received the
$44,000 federal meaningful-use incentive."

Only a few practices would
have had EMR’s that qualified for the Obama administrations meaningful –use
incentives. The Obama administration’s criteria for meaningful-use are too strict
and complex for EMR software that physicians can afford.

More amazing is that the
only way for a practice to have a positive cash return on investment for their
EMR is to game the healthcare system using their EMR. The resulting cost of
medical care would rise.

“The
largest difference between practices with a positive return on investment and
those with a negative return was the extent to which they used their EHRs to
increase revenue, primarily by seeing more patients per day or by improved
billing that resulted in fewer rejected claims and more accurate coding.”

This does not constitute an improvement in medical care. It also
contradicts the idealistic advantages of the Electronic Medical Record.

The survey concludes that current meaningful-use incentives
alone may not ensure a positive return on investment from EMR adoption.

The survey’s authors suggest,

“Policies
that provide additional support, such as expanding the regional extension
center program, could help ensure that practices make the changes required to
realize a positive return on investment from EHRs.”

The government and
healthcare insurance industry’s goal is to reduce physicians’ reimbursement to
those physicians that do not meet Obamacare’s imposed criteria for quality
medical care. The controversial Independent Physician Advisory Board (IPAB)
will set these criteria.

Many physicians in practice object to converting medical care
into a commodity. Medical care is a very personal and complex interaction not
taken into account by the rigid criteria.

I have said previously that about 50% of the therapeutic index
(therapeutic effect) of a physician’s treatment is determined by the patient
physician relationship.

"We need to move to EHR for a number of
reasons, but if I am a small practice I am going to really think about a few
things," she says. "One is how to decrease the cost of adoption and
the cost of the system itself.

“ To the extent you can reduce the upfront
cost that is going to help bring down the amount you have to figure out how to
make up elsewhere.

Increasingly there are new models taking this
into account for small practices to decrease the big upfront costs."

There are two basic issues, the cost of a fully functional EMR and
the real purpose of EMRs. I believe both can be remedied.

The costs of an EMR to a medical practice can be paid for by the
click. The data would be fully secured. The data would be available only to
patients and their physicians.

Physicians would pay for the EMR by the click. The EMRs would be
maintained and updated for free in the cloud.

The EMRs could not be used for penalizing physicians. It would
be used for educating patients and physicians thereby improving the quality of
care.

If there is a bad physician in the community, a way needs to be
found to deal with that physician within his community. All medicine is local.

This is where a consumer driven healthcare system with public
critique of physicians would be an effective deterrent to bad physicians.

The current healthcare system is defective. It has to be
changed. Obamacare is making the business plan worse.

America cannot afford it becoming worse.

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

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The False Promise of Electronic Medical Records (EMR)

March 12, 2013

inDisinformation and the healthcare system, EMR, Information Technology in Healthcare, Medicine: Healthcare System

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Stanley Feld M.D. FACP,MACE

In
2009 President Obama declared that EMRs,

“would
save some $80 billion a year, safeguard against medical errors, reduce
malpractice lawsuits, and greatly facilitate both preventive care and ongoing
therapy of the chronically ill.”

EMR’s have
done none of the above. EMRs have been a money-loser for most physicians.

I
had predicted that fully functioning EMRs were too expensive for most
practicing physicians. EMRs bought in the past were not fully functional.
Therefore physicians would have to purchase new fully functional EMRs.

Physicians
understand that all data collected, whether accurate or not, has been used
against them in the past. They are hesitant to provide more data at their own
expense that compromise the privacy of their patients and potentially harm their
own reputation.

They
would be happy to participate in the project if the EMR improved their ability
to serve their patients without a potential penalty.

Physicians
suspect there is another agenda underlying President Obama’s insistence on the
adoption of EMRs.

It
is clear the government and healthcare insurance industry want to control the
healthcare system. As the payers they do not want the physician/patient
relationship to control the healthcare system.

A
recent survey from
forty-nine community practices in a large EHR pilot study by the Massachusetts
eHealth Collaborative studied the projected five-year financial returns on
investment to physicians’ practices. It was published in Health Affairs.

The
survey concluded,

We found that the average
physician would lose $43,743 over five years; just 27 percent of practices
would have achieved a positive return on investment; and only an additional
14 percent of practices would have come out ahead had they received the
$44,000 federal meaningful-use incentive.

Only a few practices would
have had EMR’s that qualified for the Obama administrations meaningful –use
incentives. The Obama administration’s criteria for meaningful-use are too
strict and complex for EMR software that physicians can afford.

“The largest difference between practices with
a positive return on investment and those with a negative return was the extent
to which they used their EHRs to increase revenue, primarily by seeing more
patients per day or by improved billing that resulted in fewer rejected claims
and more accurate coding.”

This does not constitute an improvement in medical care. It also
contradicts the idealistic advantages of the electronic medical record.

The survey concludes that current meaningful-use incentives
alone may not ensure a positive return on investment from EMR adoption.

The authors suggest,

The government and
healthcare insurance industry’s goal is to reduce physicians’ reimbursement for
those physicians that do not meet Obamacare’s imposed criteria for quality
medical care. These criteria will be set by IPAB.

Many physicians in practice object to converting medical care
into a commodity. Medical care is a very personal and complex interaction.

I have said previously that about 50% of the therapeutic index
(therapeutic effect) is determined by the patient physician relationship.

"We need to move to EHR forward for a number of reasons,
but if I am a small practice I am going to really think about a few
things," she says. "One is how to decrease the cost of adoption and
the cost of the system itself.

“ To the
extent you can reduce the upfront cost that is going to help bring down the
amount you have to figure out how to make up elsewhere. Increasingly there are
new models taking this into account for small practices to decrease the big
upfront costs."

There are two basic problems, cost and the real purpose of EMRs.
Both can be remedied.

The costs of an EMR to a medical practice can be remedied
easily. My ideal electronic medical
record could reside in the cloud. It would be available at no cost to physicians.
The patient data would be fully secured and only used by patients and their
physicians.

Physicians would pay for its use by the click. The EMRs would be
maintained and updated for free.

The EMRs could only be used for physician education purposes and
not for penalizing physicians.

If there is a terrible physician in the community a way needs to
be found to deal with that physician within his community. This is where
consumer driven evaluation would work.

Lost in this discussion is the real politics of EMRs.

Jerome Groopman and Pamela Hartzmen
wrote,

“The
electronic medical record (EMR) is touted as the key to containing costs,
reducing errors, improving quality, and simplifying administration: an “elegant
exercise in wishful thinking

Dr. Groopman and Pamela Hartzman debunk the 2005 RAND study that
led to this belief by President Obama. They show that there is little evidence
to support the president’s belief.

Dr. Groopman claims the RAND study is self serving to software
companies that sponsored the study.

Allscripts
Healthcare Solutions , the Cerner Corporation and Epic Systems of Verona, Wis. are the major EMR software companies.

“In February 2009, after years of behind-the-scenes lobbying by
Allscripts and others, legislation to promote the use of electronic records was
signed into law as part of President Obama’s economic stimulus bill.

“But today, as doctors and hospitals struggle to make new records
systems work, the clear winners are big companies like Allscripts that lobbied
for that legislation and pushed aside smaller competitors.”

At Allscripts healthcare solutions,
annual sales have more than doubled from $548 million in 2009 to an estimated
$1.44 billion last year, partly reflecting daring acquisitions made on the bet
that the legislation would be a boon for the industry.

At the Cerner Corporation of Kansas City, Mo., sales rose 60 percent during that
period. With money pouring in, top executives are enjoying Wall Street-style
paydays.

Current and former industry executives say that
big digital records companies like Cerner, Allscripts and Epic Systems of
Verona, Wis., have reaped enormous rewards because of the legislation they
pushed for

The weird thing is many of
these EMR systems bought by large hospital systems are not fully functional
(meaningful-use). The EMRs are requiring additional hospital system outlays of
cash to make them fully functional.

These costs are passed on to
the consumer.

The president
and his health-care team have yet to address these difficult and pressing
issues. Our culture adores technology, so it is not surprising that the
electronic medical record has been touted as the first important step in curing
the ills of our health-care system. But it is an overly simplistic and
unsubstantiated part of the solution.

It is important to note Drs. Groopman and Hartzman total and
refreshing frankness.

We both voted for President Obama, in part because of his
pragmatic approach to problems, belief in empirical data, and openness to
changing his mind when those data contradict his initial approach to a problem.
We need the president to apply scientific rigor to fix our
health-care system rather than rely on elegant exercises in wishful thinking.

Please note that Drs. Groopman and Hartzman said it not
me.

I have said this many times in the past. The same statement
applies to the Obamacare in its entirety.

”We
need the president to apply scientific
rigor to fix our health-care system rather than rely on elegant exercises in
wishful thinking.”

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

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The Promise Of Health Information Technology (HIT) Through Electronic Medical Records (EMR) Is Not Fulfilled

January 28, 2013

inEMR, Medicine: Healthcare System

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Stanley
Feld M.D.,FACP,MACE

In 2005 the
RAND corporation published a study stating the HIT through EMR can save the
Healthcare System $81 billion dollars a year in a short period of time.

In
2012 HIT and EMR have not come close to fulfilling the RAND study’s prediction.

EMRs
deployed effectively can deliver that promise.

In 2009 the administration’s
stimulus package put aside $19 billion dollars in the first two years and an
extra $50 billion dollars over the next five years to stimulate and subsidize
the adoption of Electronic Medical Records (EMR) to further development of
Health Information Technology (HIT).

The RAND corporation’s 2005 study predicted
a healthcare cost savings of $81 billion dollars a year.

The RAND corporation’s study was
wrong. In the interim healthcare costs have risen $800 billion dollars

“In
our view, the disappointing performance of health IT to date can be largely
attributed to several factors: sluggish adoption of health IT systems, coupled
with the choice of systems that are neither interoperable nor easy to use; and
the failure of health care providers and institutions to reengineer care
processes to reap the full benefits of health IT.”

Many EMR software development companies have
reaped handsome benefits from the administration’s largess. These software
companies have a strategic defect in common.

These companies are trying to transform the
processes used in the practice of medicine into a process that permits the
government to commoditize the quality of medical care.

If successful the government believes it
could then “judge quality of care”
and “pay for performance” accordingly.

The goal to ensure success should be aimed at
teaching physicians how to improve the quality of medical care rather than
judging physicians’ care.

The RAND corporation’s new suggestions are
repeating the same mistakes that have failed.

“We believe that the original promise of
health IT can be met if the systems are redesigned to address these flaws by
creating more-standardized systems that are easier to use, are truly
interoperable, and afford patients more access to and control over their health
data.

Providers
must do their part by reengineering care processes to take full advantage of
efficiencies offered by health IT, in the context of redesigned payment models
that favor value over volume.”

In the meantime annual health care expenditures in the United
States have grown by $800 billion.

The new RAND study blamed the underperformance on several
factors,

“Including: sluggish adoption of HIT systems, along with
balky systems that are hard to use and aren't interoperable; and a failure by
providers and hospitals to adjust care processes to better benefit from
HIT. “

The RAND corporation is looking at the EMR problem
from 30,000 feet. On the ground many private practices and hospital systems had
previously installed information systems that cost them dearly and eroded those
providers’ net revenue.

Money is the main
impediment especially when reimbursement for physicians and hospital systems is
decreasing. Presently, physician groups and hospital systems are struggling to
remain solvent. This is partly from decreased reimbursement and partly from the
cost of ineffective non-functional information systems.

A new capital expenditure
of $65,000 dollars per physicians and $200 to $500 million dollars for hospital
systems is unrealistic even with the government’s partial subsidy. The cost
increases when maintenance fees are added.

Many hospitals simply do not have the capital
to buy systems that can cost $20 million to $200 million, especially when so
many are struggling to remain solvent. Hospitals also worry about high
maintenance costs, an uncertain payoff on their investment, a lack of staff
with adequate technical expertise and resistance from doctors.

In 2009 only 1.5 percent of
3000 hospitals had a comprehensive and fully functional electronic medical records
system “ comply with meaningful use criteria.”

The meaning of meaningful
use is all major clinical units in a hospital must perform 24 functions deemed
important by a panel of experts.

The EMR should incorporate
data points. It should include physicians’ and nurses’ notes in data point
format.

The EMR must have the ability
to order laboratory and radiological tests.

It must include clinical
guidelines defining criteria for treating various conditions. It should contain
alerts to avoid dangerous drug interactions and 20 other functions.

It is cookbook medicine all
over again. The goal is to eliminate physician judgment.

On January 1,2013 only 11
percent of the hospitals had even a basic EMR system in at least one major clinical
unit that performed 8 of the 24 functions.

Physicians have been slow to cooperate. Intuitively they
know that a functional EMR might collect data that will be used against them,

The question is will the data improve medical outcomes,
result in less medical complications and less morbidity and mortality? Will it
increase or decrease physicians work hours or increase or decrease physicians’ net
revenue?

“Pamela McNutt, senior vice president/CIO at Dallas-based Methodist
Health System, says HIT advocates were a little naïve early in the
process.

"There was a bit of over-simplistic thought that if we just purchased
and installed some software that suddenly everyone would start connecting and
talking and it is premature," McNutt says. "Even people who have met
high levels and are ready to meet Meaningful Use Stage 2 still have to work to
get efficiencies."

McNutt
says the whole idea of "efficiencies" in HIT is undefined.

"We
have to talk about what are the efficiencies we are looking for," she
says.

Accumulating
data to judge performance should not be the goal. Judging performance does not necessarily increase
efficiency.

The
EMR should improve the physician-patient relationship. It should be for the
patients’ benefit. It should not be for data collection to commoditize medical
care..

The
ideal EMR should be constructed through the eyes of practicing physicians and
not through the eyes of bureaucrats and computer software companies.

It
should be an EMR that is interoperable and compatible with physicians and
patients needs not the administration’s needs.

The
EMR should be cloud based.

It
should be secure and protect patients’ privacy.

It
should not result in a capital expenditure by physicians or hospital systems.

Provider
would pay by the transaction.

It
should not provide a financial burden to physicians and hospital systems.

It
could be updated and maintained at no cost to providers.

It
would turn an expense into a profit center for the government.

Why can’t the
administration’s healthcare policy makers figure this out?

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

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The Fourth Spoke In the Business Model For A Successful Healthcare System

February 15, 2012

inEMR, Medicine: Healthcare System

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Stanley Feld M.D.,FACP,MACE

The fourth spoke of a successful healthcare system’s business model is my Ideal Electronic Medical Record (EMR). I have been speaking about the Ideal Electronic Medical Record since 2006.

I have been an advocate of EMRs since 1992. An appropriately designed user friendly EMR would improve workflow efficiency, increase physicians ability to communicate with patients, hospitals and other physicians and reduce costs. Presently it costs physicians $7 to pull a chart.

There have been many EMRs built by many technology companies in the last 20 years. The price of an EMR has ranged from $ 5,000 to $120,000 per physician. The practice disruption to install a new system has been unbelievable.

Hospital system costs to install EMRs have ranged from $500,000 to $5 billion dollars.

In 2007 the deficiencies in Kaiser’s EMR were exposed to the chagrin of the Kaiser board of directors.

“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?

The creation of a fully functioning electronic medical record is extremely complicated. Physician practices and hospitals have different needs.

If hospital administrators are choosing a company to build the EMR invariably the software company builds the EMR for the payer (hospital). The hospital is their customer.

The physicians on staff are not their customers. Patients and physicians are their real customers but they are not considered the customer. The EMR should be built for patients’ benefit. It should be built to improve the patient physician relationship.

The EMR must be designed so that it does not interfere with the physicians' workflow and improves physicians’ care of patients.

The only way this is going to happen is if consumers are responsible for their health and healthcare dollars. Consumers will then drive their physicians to obtain a fully functional EMR.

Little progress has been made in getting large numbers of hospitals and physicians to install EMRs. There are many reasons for this dilemma. The principle reason is cost.

As the government and the healthcare insurance industry decrease reimbursement to hospitals and physicians, hospitals and physicians are hesitant to make large capital investments for EMRs.

As of 2010 only 12% of US hospital have installed at least basic EMRs. Only 2-3% might qualify for having fully functional EMRs. A fully functional EMR has to meet 23 to 25 of government imposed criteria. In 2012 these criteria define “meaningful use” developed by President Obama’s healthcare administrators.

The "minimal use criteria" will become more complex by 2014. This means the cost of upgrading an EMR will increase. Converting from ICD-9 to ICD-10 will add to the upgrading costs.

The government bureaucracy has added another gigantic hairball in the middle of the patient physician relationship.

Government bureaucrats looking at the healthcare system believe in fully functioning EMRs. Some hospital and physicians in small practice cannot afford the prices of EMRs despite the $27 billion dollar subsidy President Obama included in his Economic Recovery Act.

The $64,000 dollar maximum per physician subsidy, if they qualify, is less than the cost of the functioning EMR cost. The millions of dollars in hospital subsidy don’t match the billions of dollars in costs, service, upgrades and maintenance needed by hospitals for a functioning EMR.

No one in President Obama’s ever expanding government healthcare bureaucracy ever thought of putting an Ideal Electronic Medical Record in the cloud and charging the physicians and hospital 1 penny per click per month.

This formatting of the Ideal EMR would align the incentives of the government, hospitals, physicians’ practices and patient care.

There would be a universal EMR with automatic upgrades, maintenance and service.

Organizations that have spent a lot of money would move over to the system because they would avoid service contracts, maintenance fees and the cost of upgrades.

All the software the government felt was necessary to make the Ideal EMR completely functional would be in the system. New regulations necessitating added software would be incorporated into this Ideal Electronic Medical Record.

Practice Fusion is a new website that provides an electronic medical record for free to physicians. It is sponsored by ad revenue.

This website might have struck gold. It has grown from 10,000 users to 50,000 users in the last two years. It has meaningful use criteria embedded in the software program.

The You Tube and its accompanying You Tubes explains the system. It is easy to set up. It is free and seems secure. I still have some questions. However Practice Fusion might be right on target.

Remember, online banking did not take off until it was free.

Practice Fusion might be the disintermediator of the electronic medical records industry in healthcare just as ITunes was the disintermediator for the music industry.

Whoever said physicians are not computer literate was wrong. The only way the healthcare system is going to be fixed is if patients and physicians take the initiative without government and its bureaucratic complexity or interference.

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

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Practice fusion

Practice fusion tours.

http://www.youtube.com/watch?NR=1&feature=endscreen&v=pVYdPcqlSf8

http://www.youtube.com/watch?v=PCk1V2uuq1o&feature=related

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Nation’s Health Care Bill Predicted To Double By 2020

August 17, 2011

inHealthcare Insurance Industry, Medicare, Medicine: Healthcare System, Politicians,Healthcare and Vested Interests, Stakeholder Abuse of the Healthcare System, Stakeholder Mistrust

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Stanley Feld M.D.,FACP,MACE

Massachusetts has experienced a sixty percent increase in healthcare costs since “Romneycare” was enacted in 2006. The total cost of medical care in 2005 was $350,100,000. In 2009 the total cost of care had risen to $587,900,000. This represents an annual growth rate of 13.7% per year.

The Medicare Office of the Actuary reported it expects healthcare costs to increase from the $2.6 trillion dollars in 2011 to $4.6 trillion dollars by 2020 under President Obama’s Healthcare Reform Act.

“The Medicare Office of the Actuary estimated that health spending will grow by an average of 5.8 percent a year through 2020, compared to 5.7 percent without the health care overhaul. With that growth, the nation is expected to spend $4.6 trillion on health care in 2020, nearly double the $2.6 trillion spent last year.

I believe the Medicare Office of the Actuary growth rate estimate of healthcare costs is low. Obamacare is about expanding healthcare coverage for the uninsured. It is actually about driving the entire population into a “Public Option” which will be subsidized by the federal government. President Obama’s goal is to have total government control over the healthcare system.

The total rate of growth of healthcare costs will be greater than 5.8% per year. President Obama is not going to be able to decrease costs by insuring at least 30 million more people. Obamacare has done nothing to restrain the healthcare industry’s billing policies. The healthcare industry’s profit will escalate even further as the federal deficit escalates.

President Obama declared that Accountable Care Organizations, Pay4Performance and Electronic Medical Records would reign in costs. I believe this is a pipe dream. These programs are in the developmental stages and have an excellent chance of failing as the entitlement expands.

President Obama has continued to ignore an important healthcare cost generator. Defensive medicine generates between $300 billion and $700 billion dollars a year in costs. Tort Reform if done correctly could decrease the cost of defensive medicine to the healthcare system markedly.

“The federal health law, which will expand coverage to 30 million currently uninsured Americans, will have little effect on the nation's rising health spending in the next decade, a government report said today.’

I hope the American people do not let President Obama trick them again with his demagogary. Last week he told us he was going to decrease the federal deficit by 4 trillion dollars in ten years. It is not true because he is going to increase the federal debt by 9 trillion dollars or 4 trillion less than he had planned. Deficit spending continues unabated.

Everyone has to watch closely. He is bankrupting the country.

White House Deputy Chief of Staff Nancy-Ann DeParle tells us not to worry. "The bottom line from the report is clear: more Americans will get coverage and save money and health expenditure growth will remain virtually the same,"

She stated that the new programs that administration officials said they hope to implement would change the way Medicare and Medicaid pay doctors and hospitals. (ACOs, Pay4Peformance and EMRs). Doctor’s and hospitals are only part of the problem. A bigger part of the problem is the administrative service providers (healthcare insurance industry) expenses, the cost of government bureaucracy, and the increase in defensive medicine

“Meredith Rosenthal, a health economist at Harvard School of Public Health, said it is difficult to predict what impact the health law will have on slowing national health spending. "Many of the components of the law that are intended to control costs are still in draft form,"

The key to President Obama’s deception to the American people is to distract Americans from connecting the dots. Fifty per cent of employers will drop employer sponsored insurance programs and pay the penalty. Employees will buy insurance through the state insurance exchanges. States are refusing to participate in the insurance exchanges. The federal government is picking the ball up for the states and will have total control over the insurance exchanges.

Baby Boomers are joining the Medicare roles in increasing numbers by the minute. The cost of Medicare will escalate. Seniors are not going to be able to find physicians who accept Medicare because President Obama is going to decrease reimbursement by thirty percent January 1, 2012.

President Obama believes physicians are the problem. He refuses to believe the reality of the dysfunctional healthcare system. All the stakeholders are the problem. Some stakeholders donate more to his reelection than others. He has a strong record of playing favoritism to those that support him.

Americans are waking up to his tricks. The healthcare system has to be reformed. He has the wrong approach. I hope the electorate does not fall for his charm again.

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

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Some of Obamacare’s Complicated Mistakes

August 10, 2011

inEMR, Information Technology in Healthcare, Medicine: Healthcare System, Stakeholder Mistrust

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Stanley Feld M.D.,FACP,MACE

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

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

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

CMS’s execution of their initiatives is poor.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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The Failure Of The British Electronic Medical Record

May 22, 2011

inEMR, Information Technology in Healthcare, Innovations in Healthcare

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Stanley Feld M.D.,FACP,MACE

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

What is the solution?

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

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

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

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

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

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