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Getting Closer To The Ideal Electronic Medical Record

November 7, 2010
inMedicine: Healthcare System, Physician's Problems, Quality medical care measures
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Stanley Feld M.D.,FACP,MACE

Over 70 % of physicians use smartphones. Physicians are not resistant to learning how to use an iPhone or one of the Android smartphones. The network speed is the irritation. Networks are confusing the public with 3G and 4 G network speed. They should just do it!

We are rapidly approaching the time when a smartphone will be an appliance. The best applications will survive. Medical applications will become fully functional.

Most individual physicians and group practices have had at least one electronic medical record (EMR). None has fulfilled its promises. None has been fully functional. The price paid for the EMR was high in the era of decreasing reimbursement.

Most practices need a fully functioning EMR. The practices are hesitant to endure the pain of conversion once more.

President Obama’s multi-billion dollar subsidy program is bogus. The amount of the subsidy is well below the cost of the EMR and its continuing service and upgrades. I believe the program will have little impact on adoption of EMRs.

If President Obama provided the ideal electronic medical record along with upgrades and service to physicians for a monthly fee, physicians could afford to sign up. They would not worry about an unaffordable capital expense. Physicians would be charged by the click just as MasterCard charges by the usage.

Instantaneously, the system proposed, would result in America’s physicians converting to a government certified fully functional EMR at minimal cost or risk.

Patients’ data could be kept on a hard drive in the physicians’ office to maintain patient privacy. Physicians would have to agree to release certain data to be used for educational purposes without compromising patients’ privacy.

Instead, President Obama’s new agencies are going to use inaccurate claims data to judge physicians’ care and impose penalties on physicians.

With the increasing development of cloud computing, President Obama could provide the software in the cloud with servicing and upgrading. It would cost the government less and the government would have created an income generating business.

Electronic medical records software producer ClearPractice has developed a SAAS (software-as-a-service application) for the Apple iPad to help doctors manage their workflow, from scheduling to prescribing to billing.

A fully functioning EMR can be developed with physicians using the functionality of an iPad and upcoming Android tablets.

I have not had the opportunity to study ClearPractice’s product. ClearPractice has the right idea. Its Nimble EMR cloud product is the first comprehensive EMR application designed to run on the iPad.

I think its distribution and storage model needs refining. It also should build iPad applications to interface seamlessly with an Android system Pad.

The software can be accessed from the cloud. Patient data files can be accessed from the physicians server using a Pogoplug. This would permit physicians to be in control of their patients’ data.

“In designing Nimble, ClearPractice tackled the slow implementation of EMR software, which costs physicians time and money and disrupts their workflow. "Traditional EMR systems slow down busy doctors."

A tablet can easily keep physicians connected to their patients’ data in their office, in the hospital and at night in their home.

ClearPractice claims its software-as-a-service application has scheduling, tracking in-patient rounds, prescribing, lab review/ordering and messaging applications. It also connects to the physicians’ billing system to automatically capture and submit charges for payment.

Nimble does not sound fully functional. The software must have the ability to connect financial outcomes with clinical outcomes to be appealing to physicians. Physicians must be able to use the data they generate to augment their value to the patient. They are hesitant to submit data to a third party that will use it to devalue their worth.

ClearPractice’s fee schedule is vague. Nonetheless, ClearPractice is on the right track. President Obama could save his subsidy money if he would start listening to physicians. He is going to ahead and will waste the money from the stimulus package. He will not make progress toward the goal of developing universal use of fully functioning electronic medical records.

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

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President Obama And The Sustainable Growth (SGR) Formula For Medicare Reimbursement

June 22, 2010
inMedicare, 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

President Obama promised the AMA he would fix the defective Medicare Sustainable Growth Rate formula for calculating Medicare reimbursement to physicians. As a result of that promise the AMA supported President Obama’s healthcare reform bill.

The AMA made a big mistake supporting President Obama’s healthcare reform bill. It was as if the AMA did not evaluate the bill’s obvious unintended consequences for both patients and physicians.

The AMA lost support from not only 85% of physicians that are not members of the AMA but also from the 15% of physicians that are members.

The SGR formula makes no sense. Medicare has reduced physician reimbursement to physicians as physicians’ expenses have increased. A 21.2% decrease in reimbursement will result in physicians losing money seeing Medicare patients.

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It is stupid to lose money seeing patients. President Obama’s unintended consequence will be physicians will stop seeing Medicare patients. Physicians cannot make up the loss by increasing the volume of patients seen.

Most physicians are decreasing expenses by installing electronic medical records. The available EMRs are not fully functional. The capital expenditure is too high for most physicians. They cannot afford an electronic medical record even with President Obama’s subsidy.

A New York Times article explains the conventional wisdoms. However, there is little proof that the conventional wisdom is correct.

 

“There will likely be no real solution until the American health care system moves away from unfettered fee-for-service payments that encourage doctors to perform unnecessary and costly tests and procedures and pays them instead for better management of a patient’s care over time.”

My interpretation is physicians should get paid a salary by the government as the single party payer.

The media ignores the fact that most physicians do not get paid for the unnecessary and costly procedures.

Hospital systems and national laboratories do the tests and receive the reimbursement. The majority of physicians are single practitioners. Family Physicians and Internists cannot afford the equipment necessary to do testing in office. It is against the law for physicians to bill for testing done outside their office.

Physicians might order multiple tests that could be considered unnecessary by some. They order these tests as part of the defense against malpractice suits. Malpractice reform has been totally ignored by President Obama’s healthcare reform bill.

Until there is significant malpractice reform defensive medicine and the resulting “unnecessary testing” will not disappear. The use of appropriate data can alert the government and the healthcare insurance industry when a physician abuses the system.

The excuse of over testing does not warrant a reduction in reimbursement to Family Physicians and Internists. Doctors cannot afford to see Medicare and Medicaid patients at a loss.

It is obvious that there will be a physician shortage, long waiting periods to see a physician and rationing of care. I will discuss the complexity of the issue in detail shortly.

Family physicians and internists only have time and intellectual property to sell. The Medicare fee schedule recognizes prevention. However, Medicare does not reimburse for prevention, telephone calls or emails. President Obama talks a good game but has done nothing to correct SGR.

The “sustainable growth rate” (SGR) formula was enacted in 1997. Policy wonks concluded it was a way to restrain Medicare spending. I do not think the Policy wonks intended the consequences. The SGR set annual limits for the total amount of money to be paid in the traditional Medicare program. It also included allowances for inflation in the cost of operating a medical practice, for growth in the elderly population, and even a little extra money to pay for increases in the volume and complexity of services performed. It sounded reasonable.

The blue represents physicians’ increased in billings. The red represent application of the SGR formula. In 2007- 2009 Congress waived application of the SGR.

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“The fatal flaw in the formula was that it had no way to limit the array of services doctors provided or distinguish between valuable and needless treatments.”

“If doctors in the aggregate billings drove Medicare expenditures above the limit set by SGR, the SGR formula called for fees in the following year to be reduced.”

“ That aggregate punishment was not enough to persuade individual doctors to change behavior.”

Off course it would not change behavior. The threat of a malpractice trumps a punitive monetary penalty. It is not wise to create a punitive environment for any workers. It encourages bad behavior. Why can’t the government find the specific individuals it claims abuse the system and deal with them? The SGR is defective and needs changing. It needs to be changed along with the rules in the malpractice system.

Congress has waived the SGR formula since 2007 after physicians screamed for help. Congress did not suspend the proposed cuts. The accumulation of the yearly suspended cuts resulted in the 21.2% reduction in reimbursement this year.

I said physicians would stop seeing Medicare patients at a loss. This would hurt seniors’ access to medical care.

President Obama ignored the call for help until June 12th. He has had one and one half years to proclaim his support for eliminating the faulty SGR formula. He used the 21.2% reduction to calculate the deficit reduction effect of his healthcare reform bill.

Republicans are screaming that President Obama is spending money like a drunken sailor. Republicans decided to put their foot down. SGR was the wrong issue to put their foot down on. President Obama placed the blame on the Republicans in his weekly radio address.

 

 

“This year, a majority of Congress is willing to prevent a pay cut of 21% — a pay cut that would undoubtedly force some doctors to stop seeing Medicare patients altogether. But this time, some Senate Republicans may even block a vote on this issue. After years of voting to defer these cuts, the other party is now willing to walk away from the needs of our doctors and our seniors.”

President Obama knew Democrats did not have the votes to eliminate the SGR formula when President Obama made his grandstanding radio announcement. The suspension of SGR failed to pass. Physicians are now going to see a 21.2% reduction in Medicare
reimbursement. The AMA’s deal with President Obama did not work. It was never going to work.

The American public should be getting tired of President Obama’s games. Barney Frank and John Kerry summed up the strategy that had been developed by the Democrats long ago. No one listened. Listen again.

Now President Obama doesn’t need congressional approval to get a single party payer system. He will do it by administrative regulation.

I do not think President Obama has thought out the unintended consequences. The burden to the American public will be huge .

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

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Nothing New: Same Old Stuff Spun Slightly Differently: Part 3

September 19, 2009
inMedicine: Healthcare System, Stakeholder Abuse of the Healthcare System, Stakeholder Mistrust
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Stanley Feld M.D.,FACP,MACE

There are many disconnects between President Obama’s goal and his strategy to reach the goal of universal coverage, affordable coverage and increase in quality of care.

Universal coverage is a critical element in healthcare reform. Who is going to pay for universal coverage? Should it be the government? Should the “richer” taxpayers pay for the poor? Should physicians pay for it?

Should we ration care? Former Mayor Ed Koch (New York City) is a vigorous 82 year old male with coronary artery disease. Should he be able to decide on treatment for his coronary artery disease or should the government panel make the decision? Mayor Koch, a Democrat, is upset that the governments panel will decide for him under President Obama’s healthcare reform plan.

Affordable coverage is another goal of President Obama’s healthcare reform. Can America achieve affordable premiums without increasing deductibles, increasing taxes or rationing care? If a citizen cannot afford the deductibles who is going to pay it?

It is not plausible.

Increasing the quality of care is another important goal of President Obama’s healthcare plan. What is the definition of quality of care? Is the definition of quality what the government panels decide is quality care? Should quality medical care be defined as treating people back to health and having them satisfied with the service? Quality healthcare has not been adequately defined.

The healthcare system is dysfunctional and wasteful. How much waste is in the healthcare system? Where is the waste?

President Obama is not attacking the factors that add to the majority of the waste? He is proposing a healthcare system that is destined to create more waste. Stakeholders are profiting from the waste. Those who are profiting do not want to eliminate the waste. The healthcare insurance industry profits most from the systems’ waste.

Waste should be defined as non value added services to medical care;

 

Even with all this inefficiency and unnecessary care the average costs for the entire Medicare population including end of life issues is $6,600.00 per person. This includes the healthcare insurance industry’s administrative services fee.

Medicare Advantage was design by the government and the healthcare insurance industry to help the government unload its Medicare entitlement liability and cost over runs. The government pays an additional $3,000.00 subsidy or $9,600.00 per person for the Medicare Advantage program..

If President Obama and his administration concentrated their efforts on eliminating this waste they would not have to concentrate on reducing costs by decreasing reimbursement of physicians and hospitals.

What exactly are we paying for when we pay insurance premiums? Figure 1 is the breakdown of the percentage each segment costs. Notice in 1988 the out of pocket expenses(17.4%) for private insurance policies almost matched the entire Medicare costs(18.8%). Increased deductibles with President Obama’s healthcare plan will double this percentage. The result will not be affordable coverage. It will result in a rationing of care for everyone but predominately seniors.

DOUBLE CLICK ON EACH FIGURE TO ENLARGE

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Figure 1 Sixty five percent of private insurance dollars in Minnesota went to administrative services including brokerage fees. Only 15% went to physicians and 20% to hospitals. Figure 2

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Figure 2

"The social contract for medical care should be between the physician and patient. Private Insurers aggregate 32.6% of the dollars that Americans pay in the hope of getting care, and insurers pay out only 4.9% of the money collected from the nation’s Consumers to physicians. Insurers pay out only 6.5% to hospitals.  Administrative service fees could not possibly add 15% value to the care of a patient. The administrative service fee can and must be reduced markedly."

http://www.state.mn.us/mn/externalDocs/Commerce/Blue_Cross_anfd_Blue_Shield_of_Minnesota_051606085017_BCBSM.pdf

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Figure 3

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Figure 4

President Obama has been accused of putting the healthcare insurance industry out of business. He will not. He will continue to pay it an inflated administrative services fee. The healthcare insurance industry will be more profitable because it will have more customers and make a greater profit.

Critics of President Obama’s healthcare reform plan made these statements.

 

“The half-dozen leading overhaul proposals circulating in Congress would require all citizens to have health insurance, which would guarantee insurers tens of millions of new customers — many of whom would get government subsidies to help pay the companies’ premiums.”

"It’s a bonanza," said Robert Laszewski, a health insurance executive for 20 years who now tracks reform legislation as president of the consulting firm Health Policy and Strategy Associates Inc”.

 

The insurers are going to do quite well," said Linda Blumberg, a health policy analyst at the nonpartisan Urban Institute, a Washington think tank. "They are going to have this very stable pool, they’re going to have people getting subsidies to help them buy coverage and . . . they will be paid the full costs of the benefits that they provide — plus their administrative costs."

In his speech to congress President Obama essentially repeated his generalities. He did not get to the essence of creating affordable healthcare reform. His plan will fail to Repair the Healthcare System if it is passed by congress just as the Massachusetts plan has failed.

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

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The Electronic Medical Record (EMR) Stimulus Fiasco: Part 2

May 3, 2009
inEMR, Medicaid, Medicare, Politicians,Healthcare and Vested Interests, Stakeholder Mistrust
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Stanley Feld M.D.,FACP,MACE

President Obama is counting on electronic health records (EMR) to help modernize the nation’s dysfunctional health care system, improve the quality of care and reduce its cost. He should understand the real costs of an EMR. The cost of disruption of the work flow, the issue of incompatibility and connectivity with other EMRs, and the costs of maintenance, service and software upgrades are all important barriers not taken into account in his stimulus package. If President Obama must think that throwing money at the conversion to electronic medical records (EMR) is going to work, he is wrong. He is using the wrong route.

“His stimulus package will provide $19 billion over the next two years to promote the adoption and use of health information technology, and he has pledged to spend some $50 billion in all over five years.”

Both hospitals and physicians offices have been slow to adopt EMR’s. Most physicians would love to have EMR’s to decrease paperwork and medical errors. However, many practices have legacy EMR systems that do not provide functionality necessary. These practices are struggling with the notion to reinvest in a new EMR as their reimbursement is decreasing, cost flow is ebbing, and physician income is decreasing

“PwC estimates that the average three-physician practice can expect to invest between $173,750 and $296,000 over two years to purchase and maintain an EHR system. “

A three man ophthalmology practice was quoted $65,000 per physician plus service and maintenance. The final figure was $95,000 per physician. The EMR is fairly functional. It would not qualify for a rebate from the stimulus package.

The physicians initially complained about the disruption in their work flow. After three months they started to accommodate to the change in work flow. Now they feel they need an upgrade to add functionality. The physicians are now concerned about the maintenance and service charge per year.

“Individual physicians, not practices, can receive up to a total of $44,000 each for adopting certified EHRs.”

President Obama’s subsidy is helpful but many physicians still cannot afford the upfront cost.

“Hospital systems main impediment is money. 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, and a lack of staff with adequate technical expertise.”

There is a perverse outcome to installation of an EMR. Physicians and hospital systems may realize some return on their EHR investment. The primary returns on the physicians’ and hospital systems’ investment is expected to mostly accrue to private and public payers.

“The federal government estimates that the conversion to digital records will save $12 billion in healthcare spending over 10 years.”

The federal government saving twelve billion dollars over 10 years is a small return on a $50 billion dollar investment. The investment risk is compounded by the uncertainty of implementation of a fully functional EMR.

The survey also found that:

  • 82% of hospital CIOs have already cut IT spending budgets in 2009 by an average of 10%, with one in 10 making more drastic cuts of greater than 30%.
  • 66% of CIOs say they expect to be asked to make further cuts in IT spending before the end of 2009.

It is not difficult to understand that hospitals want to cut costs. They are reporting cash flow and profit margin problems. The government cannot afford Medicare and Medicaid in its present form. President Obama’s plan is to expand both Medicare and Medicaid while decreasing patient coverage and provider reimbursement. Premiums for Medicare and deductibles have been increasing steadily.

  • 64% of CIOs agreed that it is impossible to balance demand with the need to cut costs.
  • One-half of CIOs with more than 500 beds say that federal funding is "crucial" to their ability to implement EHRs.

The stimulus formula for subsidizing hospital systems is a function of the hospital system’s volume of Medicare and Medicaid patients. With government reimbursement decreasing, hospital systems are reinventing themselves to attract paying customers. They are developing high productivity profit centers such as back centers, cardiovascular centers, and gastric bypass centers. Hospital systems “lose money” on acute illnesses. Hospital systems are trying to move away from their dependence of Medicare and Medicaid patients.

It should be obvious that President Obama’s EMR stimulus plan has not been well thought out.

The American Medical Association seems to be on the right track. It is clear to me that someone is listening to me.

“The American Medical Association is developing a Web-based service offering doctors electronic prescribing, up-to-date reference material and other resources.

The idea is to make it easier for physicians to adopt technology President Obama is promoting for health care reform, to streamline their workload, and improve patient care.”

“Doctors will be able to use it to access numerous electronic medical services, including the latest science on diseases, and electronic health records, said Dr. Joseph Heyman, chairman of the AMA’s board.”

http://news.yahoo.com/s/ap/20090422/ap_on_bi_ge/us_med_ama_electronic_health_1

There are no details available yet. It is encouraging that the AMA is trying to be proactive.

President Obama, this is not rocket science. If you put a totally functioning electronic medical record in the cloud in the next few months, the most it should cost the government (taxpayer) is about 5 billion dollars.

The software could be serviced and upgraded at no cost to the providers of healthcare services. The taxpayers return on the dollar would be at least three times that amount in the first year if the providers paid by the click. Payment by the click would not be a burden to physicians or hospital systems.

Physicians and hospital systems would instantly have a fully functioning EMR. The government could use the same business plan credit card companies use. It could even set up an auto pay system.

President Obama, I hope you read this and arrive at an "ah ha" moment and change the route you are taking to convert medicine to an electronic information system.

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

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Healthcare Is A Team Sport

April 26, 2009
inEMR, Medicine: Healthcare System, Patients Problems, Quality medical care measures
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Stanley Feld M.D.,FACP,MACE

Healthcare is a team sport. The patients are the most important members of the team. They are the players. Physicians are the coaches. They should be adjusting their recommendations after receiving maximum data from the patients. Patients must become the “professors of their disease”. In order to have a successful team, physicians need several assistant coaches. The physician extenders must not be physician substitutes. Physician extender are nurse educators, dieticians, psychologists, social workers and exercise therapists. Patients must be at the center of the healthcare team and relate to the entire team in order to have maximum knowledge about their disease. It requires a great deal of responsibility on the part of the patient.

I chaired the American Association of Clinical Endocrinologist Diabetes Guidelines in 2002 in which this team approach is outlined. The AACE diabetes guidelines also contains a patient/physician contract. It spells out the responsibilities of the patient and physician. The team unit cannot be successful if the assistant coaches act independent of physicians.

The internet can provide some infrastructure to aid the assistant coaches. So far, internet based information has not been an extension of physicians’ care (Healthcare 1.0). It has been a failure. The internet assets developed (some of which have been good) have proven to be ineffective in repairing the healthcare system.

Jennifer McCabe Gorman understands the problem. She is working diligently to promote the concept of connecting internet based patient centered information with physicians care (Healthcare 4.0). I believe she understands the concept of patient centered healthcare with healthcare as a team sport and physicians as the leaders of the team. I believe she has the passion and ability to translate this vision into reality.

Until now content on the internet has provided generic information about chronic diseases. Most of the information lacks context and nuance. Most of the internet content does not explain the pathophysiology of the disease process. Internet content out of context tends not to be helpful. Some of the content is inaccurate.

Jen McCabe Gorman describes Web 2.0 as a combination of content and social networking. Disease based social networking is growing rapidly and rightly so. We are all social beings starved for information. We need and seek disease based social interaction. Social networks give patients the opportunity to cluster by disease and share their experiences with a disease process. This can be helpful. However, its limits must be understood. Individual patient uniqueness and disease variation must be taken into account. It would be wonderful if the social network were an extension of the individual patient’s physician’s care. Physicians will gradually understand its value as a teaching tool to help patients become “professors of their diseases”. Presently disease based social networks act as physician substitutes. This use decreases both physicians’ and social networks’ effectiveness.

Patients live with their disease 24/7. If patients understand the dynamics of their chronic disease, they and their physician can be more effective in their decision making. Patients would have a better chance of controlling their disease and avoiding the costly complication of the disease.

I believe that repair of the healthcare system can be partially achieved with effective disease specific social networks as an extension of physicians’ care. Social networks are not focused on that goal yet(Healthcare 2.0). The goal is to get to Healthcare 4.0

Healthcare 3.0 is what Google Health and Microsoft’s Health Vault are trying to do with an internet based Personal Health Record (PHR). I predict they will fail. It is not connected to physicians care. My wife and I carry our PHR on a key ring flash drive. The PHR could easily be carried in an IPhone.

Patients must express outrage and force their physicians to utilize the medical records patients have gathered. Patients input into their own care, control of their own data, participation in the treatment decision making and being responsible for their care is the only way to reduce costs and avoid chronic disease complications.

Healthcare 4.0 will arrive. With the expansion of social networking we are developing more sophisticated patients who will become sophisticated consumers of healthcare. Patients will demand functional EMRs from their physicians. Only then will disease specific social networks become an extension of the physicians care and effectively decrease the complications of chronic disease.

The two primary stakeholders in the healthcare system are the patients and the physicians. All other stakeholders are secondary stakeholders. Additionally, it is essential that all the stakeholders align their collective vested interests in order to repair the healthcare system. With the development of internet based assets including a fully functioning EMR the alignment of vested interests will occur because patients will be empowered to demand it.

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

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President Obama; If You Really Want To Reduce Healthcare Costs, Effectively Reform The Medical Malpractice Tort System ?: Part 1

April 7, 2009
inDisinformation and the healthcare system, Medicine: Healthcare System, Politicians,Healthcare and Vested Interests, Stakeholder Mistrust
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Stanley Feld M.D.,FACP,MACE

President Obama, you have not discussed the need for medical malpractice reform. Without medical malpractice reform you will not be able to reduce the cost of healthcare and increase the quality of medical care. It will be difficult because malpractice reform goes against the vested interest of some of your major supporters, plaintiffs’ malpractice attorneys.

There is at least one trillion dollars of waste in our $2.3 trillion dollar healthcare system. One hundred fifty million dollars ($150 million dollars) is wasted on excessive administrative costs by the healthcare insurance industry. The remainder is generated by the practice of defensive medicine and cost of malpractice insurance.

“Much of this waste is generated or justified by the fear of legal consequences that infects almost every health care encounter. The legal system terrorizes doctors. Fear of possible claims leads medical professionals to squander billions in unnecessary tests and procedures.

Physicians and nurses are afraid to speak candidly to patients about errors. They try to explain the risk reward ratio of treatments for fear of assuming legal liability. The result is the practice of defensive medicine and over testing to cover every possible contingency. This legal anxiety is also corrosive to the therapeutic magic of the physician patient relationship.

It would be relatively easy to create new rules that would provide a reliable system of justice for patients harmed by medical treatments and procedures without encouraging costly litigation. If a new system was in place it would decrease the costs of defensive medicine significantly. It would encourage physicians use of clinical judgment rather than expensive tests and improve the physician patient relationship.

“ The good news is that it would be relatively easy to create a new system of reliable justice, one that could support broader reforms to contain costs.”

Everyone makes mistakes in every walk of life. The legal liability threat could generate further unnecessary errors. Physicians, nurses and hospitals are advised not to offer explanations about a mistake. Sometimes errors are concealed to avoid a legal ordeal. The hidden error could be compounded by additional mistakes.

“Even in ordinary daily encounters, an invisible wall separates doctors from their patients. As one pediatrician told me, “You wouldn’t want to say something off the cuff that might be used against you.”

There are cost multipliers created as mistrust accelerates between the patients and physicians. You would like physicians to adopt electronic medical records. Some physicians avoid using EMRs because the information could be misinterpreted and used against them. There is an increasing use of second opinions. Every examination requires an observer for the examination to avoid legal liability. Every problem requires multiple laboratory tests to rule out something that might have been missed. An example is a CAT in the Emergency Room for even the slightest head trauma.

“Medical cases are now decided jury by jury, without consistent application of medical standards. According to a 2006 study in the New England Journal of Medicine, around 25 percent of cases where there was no identifiable error resulted in malpractice payments.

“Nor is the system effective for injured patients — according to the same study, 54 cents of every dollar paid in malpractice cases goes to administrative expenses like lawyers, experts and courts.”

These are the major tort reform issues. They must be addressed to decrease wasteful expenditures in the healthcare system. Malpractice lawsuits are a growth industry for defense attorneys, a burden to physicians having to defend themselves and a significant cost to the healthcare system. Malpractice reform is essential to any meaningful healthcare reform. President Obama, I think you know it. The question again is will to take the correct route to reform the malpractice tort system.

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

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Congressional Budget Office Reveals Budget Hurdles In Financing Healthcare Reform

January 11, 2009
inUncategorized
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Stanley Feld M.D.,FACP,MACE

 

The Congressional Budget Office report states that President-elect Obama’s healthcare plan would carry a high price tag. The healthcare plan would generate only modest savings.

“Mr. Obama and other Democrats have not been precise about the cost of their proposals, nor have they said in detail how they would pay for them.” Some of the options, including proposals to increase taxes on cigarettes and nondiet soft drinks, are sure to meet stiff political opposition.

President-elect Obama has not been precise about any of his proposals on purpose. Both political parties say they will make a serious effort to overhaul the health care system in 2009. In our current economic crisis it is essential to that. As unemployment rises the uninsured population will rise. The fear in the population will create pressure on congress to pass any bill that promises hope and relief.

However, President-elect Obama’s transition team is going about the overhaul of the healthcare system the wrong way. I am positive they think they are doing it the right way.

“One bright spot in a generally bleak picture was the estimate of potential savings from a requirement for doctors and hospitals to use health information technology (EMR), including electronic medical records, as a condition of participating in Medicare.”

Such a requirement could save the federal government $7 billion in the first five years and a total of $34 billion over 10 years, by reducing medical errors and avoiding unnecessary tests and procedures, the budget office said.

President-elect Obama does not plan to create a universal electronic medical record. Electronic medical records are essential to repair the healthcare system. The administrations healthcare transition team believes it can force physicians to purchase, install and service electronic medical records most physicians cannot afford. The government plans to make EMR a condition to participate in Medicare. Many physicians would not mind being forced out of Medicare.

Most installed EMRs in large hospital systems are not fully functional. Many do not have total functional cross hospital system compatible interfaces that would allow efficient flow of information. Most EMRs do not allow for real price transparency that can stimulate efficient use of healthcare system resources.

If the government requires physicians to buy an EMR by penalizing them, physicians will drop out of the Medicare program. The result will be the creation of a shortage of physicians. The government should make available a fully functional EMR free of charge. It should not require a capital outlay. Physicians would pay by the click monthly.

Without action by Congress, the report said, health costs will continue to soar, the number of people without insurance will rise by nearly one million a year, to a total of 54 million in 2019, and spending on health care will increase to 25 percent of the gross domestic product in 2025, up from 16 percent in 2007.

All agree that something must be done to repair the healthcare system. The Congressional Budget Office (CBO) must work with the data they have even if the data is incomplete. CBO’s estimates are modest. During our present economic recession I think the number of uninsured will rise to 54 million by the end of 2009, not in ten years.

“Lawmakers from both parties said they would pay close attention to the cost of new federal subsidies for health coverage because these subsidies — unlike the one-time bailouts for banks and other financial institutions — would be recurring federal obligations for years to come.”

A large problem is that all the proposals would force a stakeholder to do something. In order to accomplish real change the government needs to provide incentives for stakeholders, not mandates. Historically, mandates never work.

1. Requiring employers to provide health insurance to their employees.

1a. or pay a fee to the federal government would bring in $47 billion of new federal revenue in the next 10 years, the report said.

The savings of 4.7 billion dollars a year is insignificant in a healthcare system that has 150 billion dollars of administrative waste a year. The government should go after the administrative waste.

A proposal to establish a national insurance pool for people who cannot obtain coverage on their own in the individual market would cost $16 billion in the next decade in subsidies.

The real issue is the need to put the individual market on a level playing field with the group market. Secondly, it is essential consumers be in charge of their healthcare dollar. Presently the healthcare dollar is owned by the healthcare insurance industry. Ownership of the healthcare dollar will remain with the healthcare insurance industry in a President-elect Obama’s administration.

Mr. Obama and many other Democrats want the government to negotiate with drug manufacturers to get lower prices for Medicare beneficiaries.

This is an important action. Medicare Part D is a structural disaster. Medicare Part D has to be restructured to be in favor of the consumer, not the healthcare insurance industry. Part D was a good idea turned into an overpriced plan. The plan does not improve patient compliance because patients cannot afford the medication. The result is that it will not decrease the complication rate of chronic disease.

But the budget office said Medicare could save $110 billion in the next 10 years if Congress simply imposed a form of price controls, requiring drug makers to provide the government with a 15 percent rebate, or discount, on brand-name drugs covered by the new Part D of Medicare.

Historically price controls do not work. Incentives and competition work, if Medicare Part D was structured correctly there would be no overcharging for medication.

Under the current proposals the saving would be insignificant compared to the rising cost because President-elect Obama’s team is trying to fix the wrong things.

Doing what they are proposing is going to result in a more expensive healthcare system. The result will be cost overruns and a decrease in access to care and quality of care.

We have all experienced inefficient government rules and regulations. We must brace ourselves for the worse and start understanding the deficiencies now so we can speak out with one voice.

 

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

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Most Doctors Aren’t Using Electronic Medical Records: Part 3

August 3, 2008
inEMR, Medicine: Healthcare System
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Stanley Feld M.D.,FACP,MACE

 

The New York Times article presents me with an opportunity to discuss the issue of the adoption of EMR in physician terms. Media reporting tries to be neutral and informative. It usually produces nothing but confusion.

“The report published in the NEJM also found that electronic health records were used by 51 percent of larger practices, with 50 or more doctors.”

The EMR adoption rate by large physician groups of physicians is still low. 49% of large practices still do not have an EMR.

“Indeed, electronic health records are pervasive in the largest integrated medical groups like Kaiser Permanente, the Mayo Clinic, the Cleveland Clinic, University of Pittsburgh Medical Center and others. These integrated groups not only have deep pockets. By combining doctors, clinics, hospitals and often some insurance they can also capture the financial savings from electronic health records.”

A year ago Kaiser Permanente had was embroiled in a scandal concerning its 3 billion dollar investment in information technology system which includes an EMR.

“ In the e-mail, Justen Deal, a project supervisor who has worked for the company for two years, detailed his frustration with Kaiser’s electronic health record system, which he considers inefficient and unreliable.” “Deal was placed on administrative leave.”

We have little information about the effectiveness of Kaiser’s EMR presently yet it is presented as a successful system in the New York Times article.

The promise of an EMR must be realized in the next few years. Only innovative thinking will precipitate the necessary paradigm shift toward EMRs rapid adoption. It must be done quickly before it is too late.

Using an EMR can provide finger tip information to physicians about patients they treat. If set up correctly it can speed up data entry on patients and be a guide to complete data entry for particular diseases. It can serve to improve the quality of clinical decision making by interconnecting to clinical practice guidelines. It can be used to avoid medication errors with the use of e-prescription and can point out potential drug interactions. It can be used as a guide for patient education to prevent the complications of chronic diseases. It can increase productivity of physicians by electronic delivery of laboratory findings. It must be formatted as a physician extender and not a physician substitute.

After a sometime steep learning curve physicians are satisfied with the electronic medical record. The NEJM study was a little exuberant with its statistic reporting that over 80% of the physicians were happy they had an EMR when the EMR was fully functional (3.2%). Not all EMRs in large clinics are fully functional.

The study found that a paltry 4 percent of the doctors had a “fully functional” electronic records system that would allow them to view laboratory data, order prescriptions and help them make clinical decisions, while another 13 percent had more basic systems.

Within a large clinic the electronic medical record should be totally transparent to the physicians across clinical and business functions. Patients can log in and get their records and laboratory results, physicians interpretations and radiological findings immediately and have a PMR (Personal Medical Record). The EMR could also improve communications with other physicians.

Dr. Peter Masucci, a pediatrician with his own office in Everett, Mass., embraced electronic health records to “try to get our practice into the 21st century.”

He could not afford conventional software, and chose a Web-based service from Athenahealth, a company supplying online financial and electronic health record services to doctors’ offices.

There are not many physicians in the United States that would trust their records to be outsourced at this point in time. However with the proper protections web based online electronic medical records could work.

“Dr. Masucci was already using Athenahealth’s outsourced financial service, and less than two years ago adopted the online medical record.”

Today, Dr. Masucci is an enthusiast, talking about the wealth of patient information, drug interaction warnings and guidelines for care, all in the Web-based records.

“Do I see more patients because of this technology? Probably no,” Dr. Masucci said. “But I am doing a better job with the patients I am seeing. It almost forces you to be a better doctor.”

This is a reason we need a ideal and universal EMR. However, the ideal EMR must have the ability to be used as an educational tool for patients and physicians. EMRs should be standardized and then customized by physicians to mimic physicians practice patterns. They should make medical care more efficient and less costly. Dr. Masucci is simply a testimonial stating that he has gotten rid of his paper record. However it might not be increasing his problem solving ability or his ability to transfer information or treat chronic diseases using evidence based medicine. The problem with most EMRs is they do not provide full functionality needed to solve the many problems in the healthcare system.

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

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Most Doctors Aren’t Using Electronic Medical Records! : Part 1

July 27, 2008
inEMR, Medicine: Healthcare System, Quality medical care measures
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Stanley Feld M.D.,FACP,MACE

Why do physicians seem resistant to the use of Electronic Medical Records (EMRs)? The answer is there are at least three barriers to adoption of EMRs that healthcare policy wonks seem to ignore that must be cured.

The New York Times reported on a survey published in the New England Journal of Medicine that less than 9% of physician in small physician office practices use EMRs? The major barrier is these small physician practices cannot afford to buy them and do not know which EMR to buy.

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There are different sized medical practice groups in the United States. However, more than 50% of physicians practice in groups of one to three physicians. The survey points out that the smaller the group the less likely they are to have an EMR.

“Dr. Paul Feldan, one of three doctors in a New Jersey practice, said switching to electronic records did not make economic sense.”

I have described the ideal electronic medical record. I have also emphasized that the patient should own the record. Its distribution should be exclusively in the hands of the patient. Technology exists to create a fabulous electronic medical record. The data generated could increase the quality of medical care and decrease medical errors. The result could be an enormous decrease in the costs to the healthcare system.

So why is the medical community slow to adopt the EMR? The government sponsored survey points to two contradictory conclusions.

The New England Journal of Medicine published survey found that doctors who use electronic health records say overwhelmingly that such records have helped improve the quality and timeliness of care.

Dr. Peter Masucci, a pediatrician in Massachusetts, said shifting to computerized records helped improve his patient care.

The meaning of the concept of quality medical care should be obvious but is complex. The judgment of quality medical care by a computer program is frequently wrong. This, in my opinion, is the major problem with the present Pay for Performance fad. It is an attempt at a judgment of quality that results in a punitive action against the doctor rather than being an educational experience for him or her.

Physicians in private practice have been slow to adopt EMR’s for at least three reasons.

1. They do not have the financial resources to spend $25,000 to $80,000 per physicians to purchase an EMR. The range of cost for an EMR implies differences in quality and capability of the various EMRs on the market. Many physicians have made investments in EMRs only to find them to be deficient in many areas. The initial investment does not include a yearly maintenance service contracts or updates. Many EMRs lack adequate software support. Physicians do not have the skill or want to devote the time to figure out the best deal.

2. A second reason is the lack of financial incentives to purchase an EMR. The EMR might help the healthcare insurance and government accumulate data about physician practices and patients care. It might save money for these stakeholders but there are no assurances that the saving will be passed on to either physicians or patients. The promise of the EMR is it should increase productivity and decrease practice overhead. Physicians should be able to decrease the number of full time employees. In most cases this does not happen.

3. Patient privacy is the third barrier. In reality, at this moment patient privacy is non existent with paper records. If patients want to buy healthcare insurance complete medical histories are required by the healthcare insurance company. An EMR would make it easier for the healthcare insurance industry to evaluate a patient record and restrict a patient’s access to healthcare insurance. The element of mistrust by physicians and patients toward government and the healthcare insurance industry is difficult to erase.

The point of patient mistrust was expressed in late June when a House of Representatives committee introduced new healthcare privacy legislation that does not adequately protect patient privacy. The American Civil Liberties Union was the first to protest.

“Leaders of the Energy & Commerce Committee introduced H.R. 6357 this week, and the health subcommittee approved it on June 26. The full committee, as well as two other House committees, now will consider the bill.”

“The legislation lacks provisions to enable patients to review their own files and make corrections, decide who has access to personal health information, or simply opt out, according to ACLU.”

Caroline Fredrickson, director of ACLU’s legislative office in Washington, said in a statement. “If this legislation gets approved, Americans’ medical secrets will be extremely vulnerable to being lost, stolen or sold to the highest bidder.”

I have stated previously that mistrust of the secondary stakeholders by the primary stakeholders in the healthcare system, physicians and patients, must be understood by healthcare policy makers. The issue of mistrust has to be resolved if any progress is to occur in accelerating physician adoption of the EMR.

Both the government and the healthcare insurance industry seem to encourage this mistrust unintentionally by introducing punitive measures to solve the healthcare systems’ problems. These measures simply heighten the primary stakeholders’ cynicism and mistrust.

More on EMRs to follow.

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