Stanley Feld M.D., FACP, MACE Menu

All items for April, 2009


The Electronic Medical Record Stimulus Fiasco: Part 1

Stanley Feld M.D.,FACP,MACE.

All of President Obama’s goals are commendable. The United States needs to fix the education system, decrease its dependency on fossil fuel, increase production of renewable energy, and repair the healthcare system.

These are all big ideas. They must be implemented for the United States to prosper in the future. I have expertise in (healthcare). President Obama’s route to achieving healthcare reform is wrong. He is not attacking the basic problems in the healthcare system.

A PriceWaterhouse Cooper study showed $1.2 trillion dollars is wasted on defensive medicine and administrative costs. Where is malpractice reform on President Obama’s list of big ideas to eliminate the practice of defensive medicine?  If the $1.2 trillion dollars of waste were eliminated we would have an affordable healthcare system.

The administration’s stimulus package for instituting an electronic medical record (EHR,EMR) is going to create more waste and a larger mess than the fiasco that already exists.

“A recent Robert Wood Johnson survey of more than 3,000 U.S. hospitals found that only 9% were using electronic health records (EHR). “The numbers are disappointing and certainly lower than we thought when we went into this study,” says Ashish Jha, the lead author of the study and an associate professor of health policy and management at Harvard University. “

The survey is a well done. Survey responses were received from 63.1% of all acute care hospitals that are members of the American Hospital Association. This is a high percentage response rate for a survey. The survey looked for the presence of specific electronic-record functionalities. More discouraging than the 9% figure is only 1.5% of U.S. hospitals have a comprehensive electronic-records system (i.e., present in all clinical units and fully functional).

Only 7.6% of acute care hospitals have a basic system (i.e.present in at least one clinical unit). Computerized provider-order entry for medications has been implemented in only 17% of hospitals. Larger hospitals, urban area hospitals, and teaching hospitals were more likely to have electronic-records systems than small hospitals in smaller cities. Most of the hospitals spent over $100 million dollars for it EMR. The money spent did not enable the hospital systems to implement a fully functioning EMR.

Hospitals and hospital systems are experiencing financially hard times during this recession. They cannot afford the capital requirements and high maintenance costs to implement the installation of an EMR when the end result is not having a fully functioning electronic medical record. Hospital systems board of directors are not interested in going deeper in debt when the government is going to reduce reimbursement for non compliance.

PriceWaterhouse Coopers’ analysis of the stimulus package for EMR points out government subsidies are through the traditional EMR acquisition channels. Their analysis highlights the government’s punishing actions of non compliant providers. It is going to reduce reimbursement as punishment. Isn’t that silly? The government should be worrying about the financial health of these institutions and physicians’ practices

“The stimulus funding for health IT is a small carrot compared to the amount of resources it will take to deploy this technology over the next 5 years. Also, providers will feel a big stick of financial penalties if they fail to use government-certified electronic health record (EHR) in a government-certified manner beginning in 2015.”

It should be obvious that every physician’s office and hospital system should have a functional electronic medical record. One must wonder how physicians feel when they cannot afford an EHR that will probably not have full functionality.

Who will be the winner? Patients should be the winner. Patients will not win under President Obama’s stimulus package.

“With billions in new funding and government regulations, the health IT market will balloon far beyond the provider segment, providing new opportunities for health plans, pharma companies and other vendors.”

Powerful secondary stakeholder with financial vested interests will win.

The net result is will not be a universal and functional EMR. There will be little connectivity.

The government should invest in the purchase of a web based fully functional EMR with all the attributes necessary to build an effective electronic medical record system. The system would provide complete interconnectivity to physicians, hospitals, pharmacies, and insurance companies. Upgrades and maintenance of the software would be automatic and free.

The government would charge each provider entity by the click for the use of the universal Electronic Health Record. The government would recover its investment over a very short time and instantly create a system of price transparency. The system would be affordable to the healthcare providers. The present stimulus plan for EMR is going to waste the $36 billion dollars. It will try to force hospital systems and physician offices to buy an electronic medical record system that they cannot afford, do not want and might not work.

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

  • Jay Beaulieu

    As an IT worker I am also worried about the President’s Healthcare IT reform. First thing I’d like to set straight is that you presented a serious series of issues about Healthcare IT and I’m going to try to address them. I don’t stand to benefit at all from my solution. I also tried contacting the Obama administration and sent the following viewpoint that implied SOA (XML contracts, workflow) and DITA (data views, procedure workbooks) both are open source, but received no response:
    I want to keep this letter at the concept level and not get into a technology whitepaper, but rest assured everything I’m about to suggest is at the cell-phone level of cost for physicians, a little more at the hospital level because of different needs but most importantly the technology already exists.
    There are currently three basic types of medical records, paper medical records, the folder we all know so well, the electronic medical record used mostly at hospitals, think of a printout from a computer system and the Electronic Medical Records (EHR) which are XML-based records that have the ability to reduce costs and errors because they are programmable and can be validated (checked for accuracy and completeness.)
    The first discussion we need to have is who should hold these records. If the goal is to fight disease, find new cures, to identify epidemics and to use these records as a basis for an unparalleled growth of healthcare knowledge over the next ten to fifteen years, we need the records easily and securely accessible. There are two groups that I think have the ability to deal with the billions of pages of medical records. The first is the Federal Government but due to the boom and bust of the budgetary process I prefer the telecoms because they are big enough, have the redundancy, the geographical reach, the competition, the bandwidth and their business model is based on providing reliable services at a low cost.
    Next we need to look at what is the correct paradigm to use for our medical records. This is simple it’s an electronic loose-leaf notebook that mimics a paper folder but has pages that can be forms or entire computer systems like an MRI system. A simple example would be using the Kindle II to access medical records. Because most physicians medical records are in paper form we need to get them scanned into electronic form and sent to the telecoms. This is labor intensive but requires little training; we could use the workers already being assembled for the 2010 census, providing a very quick stimulus effect across the country. This is not make-work because the unfiltered raw data is the most valuable form of information to researchers if searchable. The census worker leaves behind a scanner, a printer driver (to write to the telecoms) and an electronic certificate of use that allows secure and audited, reading and writing to the medical record. The electronic certificate of use controls the type of information the holder can view or update. For instance, a state worker that monitors lead levels may be able to add a report to the book but never read any information and the same would be true of a Department of Children and Family welfare worker. This information could have a direct impact on treatment choices. The census worker also performs an audit of what software systems that are currently in use at the office, for later when we convert to XML.
    At the hospital level we could use the same type of system as at the physician’s office but here since money is available we want to make use of it for future efficiencies. So the first step is to think of each computer system, medical device and medical personnel’s duties as steps in a workbook. The goal is not to run out and replace every computer system you have but rather to identify workflows and steps so that you can layer with an enterprise software service on top of whatever systems and procedures you are currently using. This is the best way to keep integration and training costs to a minimum. This first step sets the basis for measuring metrics across the hospital and after careful analysis selected systems could be replaced. The idea is that the use of EHR records can be implemented outside or on top of your current systems. Disk space is cheap and redundancy of information is not always a sin.
    At this point we’ve minimized the risk of movement to XML. The physician’s office has had time to adapt their workflow to electronic records, has probably replaced the paper folder racks with another examination room and may have had some cost savings. And they no longer have to worry about marrying an IT person to practice medicine. The telecoms are trying to sell all sorts of services like billing, automated reminder calls, electronic prescriptions the list is endless. The hospitals have identified its different workflows, decided where XML would benefit them and possibly received bids from different software vendors to wrap the individual systems either wholly or partially to take advantage of XML. Now it’s time to move to XML.
    The largest cost savings and reduction of medical errors comes not from the EHR record but from the workbooks. This type of workbook is really a best medical practice workflow, in it’s infancy it’s just an electronic record of symptoms, treatment and justification, sent to a third-party like a telecom. The purpose is to prevent a remake of the “Verdict” with Paul Newman except on the History Channel. But to do that the workbooks need to be created and maintained not by an individual software vendors or physicians but by a consortium of interested parties like the medical manufacturers, pharmaceuticals, medical associations, physicians groups and finally the Federal Government for an effectively rating. This allows for the creation and refinement of many backend programs that can check on the validity of treatments in so far as medical errors and options are concerned.
    Next up are the healthcare insurance providers. Because the medical community has its own very precise terminology, what’s covered, partially, wholly or not at all by an insurer can be conducted in an XML contract in a matter of seconds. This would require a law to be passed requiring it from the insurers. But it should also allow the insurers to provide an alternative treatment to the patient. This provides the patient a cost with an effectively rating and maybe a couple of different optional
    treatments so the patient in consultation with their physician makes the judgment.
    We left the medical records as electronic medical records earlier we need to get them into EHR but I’m of three minds here. The first is that we could have done the conversion when the records were scanned in and using software and our census workers create the EHR, this provides the greatest stimulus to the most people. Or we could scan them in and have the conversion done in places like Elkhart, Indiana or other areas hard hit by this recession, because most people that have worked in a factory or assembly line already have the skills needed for XML. But we could also write software programs to parse, categorize, and convert the data to EHR which would produce valuable programs that could be used outside of our medical records, to XML and Artificial Intelligence programs in general. The programs are re-executable whereas using the census workers is more of one shot deal. The other thought is that when designing the XML processing procedures it should never be pigeon-holed into what we expect to collect for information. A notebook can have anything in it but a page or maybe even a chapter could be validated but it needs to be remembered this is a data collection system that must change frequently with the pathogens and treatments out in the field. Layered from the unknown but collected (notebook) to the known (page) outside in.
    Now the medical office worker, physician and patient all check the accuracy of the EHR. From the physician’s point of view, forms can now be filled out on the hand-held device, new features or workbooks appear tailored to their specialty and particular treatments. Perhaps a table of relatives allows access or just querying the patients relative’s books for pertinent information, but of course this is up for discussion. The hand-devices could now have barcode readers, GPS units and biometric fingerprint readers for drug auditing, security and for access auditing. Deceased people’s books are constantly being sent to the National Archives or CDC for storage and research, a little like donating your body to science without the yuck factor.
    Hospitals have spent there monies wisely, have color-coded hand-held devices so they don’t bring the wrong one into the operating room. But most importantly, they’ve changed from, a who can pay and who can’t, to true cost accounting and I don’t mean in the IRS sense. But we as a society need to actually advance not to just pay as you go. So therefore, charging ten dollars for an aspirin from an IT perspective, I can’t help you. However, if the reason you’re charging ten dollars is to
    offset the fact that you have a separate DBA for each database or you need 24/7 support there I can reduce your costs significantly.
    Finally, we’ve created a series of checks and balances in our healthcare engine that should help it stop leaking oil. We’ve given everyone a haircut to one degree or another but we’ve refocused on the fact that the goal of our healthcare engine should be on providing better healthcare for ALL Americans and that profits should be earned though innovation and hard work not just by exploiting leaks in the system or clever accounting.

  • EMR Medical

    Thanks for the view through this blog. A major US survey has shown lately that majority of doctors think implementing electronic medical records is necessry at this time.

  • •••
  • Thanks for leaving a comment, please keep it clean. HTML allowed is strong, code and a href.


Healthcare Is A Team Sport


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.

  • Dr. Davon Jacobson, MD

    This is really a well laid out website. I like how you have presented the information in full detail. Keep up the great work and please stop by my site sometime. The url is

  • Stephen Holland

    It looks like hospitals are marginalizing physicians. Cardiology practices are now mostly hospital owned. Hospitals are buying medical practices regularly. EMRs are being selected by hospitals, not physicians. The ownership of the EMR establishes the branding of the practice and creates defacto referral systems among specialities that share the EMR. We physicians are letting this happen. My colleagues tell me I’ll just have to get used to the EMR cause that’s the way it’s going. It so frustrates me to see hospitals choose winners and losers in referral patterns. It will become nearly impossible to form new medical groups when all groups essentially have become parts of multispeciality groups. Competing single specilaity groups, which is the basis for the quality drive in medicine today, will disappear, and the satisfaction of hospital administrators will determine if a group is viewed favorably. Of course, that means that groups that refer most to the hospital will be the most rewarded. Surgicenters will be hit, hospital outpatient care will cost more, less patients will be served, doctors will be less efficient, and patients will have to wait.

  • •••
  • Thanks for leaving a comment, please keep it clean. HTML allowed is strong, code and a href.


From My Perspective: The Power of Play

Cecelia Feld

I’ve had many requests for guest blogs, so I thought I’d start with one by someone who has not asked, my wife, Cecelia. (A little nepotism goes a long way). Stanley Feld M.D.,FACP,MACE

Do you play? Or, because you’re all grown up, have you forgotten how?

I recently had the opportunity to stay with my granddaughter for a few days while her parents took a mini vacation. The wonderful thing about being a grandparent is being able to step back and reflect on the experience, something difficult to do as a parent (lack of time, energy). Fun for an almost five year old (or four and 11/12’s as Sabrina will tell you) comes in many guises, often free or at little cost. Fun = play; play = fun. Learning is fun. Is there anything she is not interested in? No. Is there anything she won’t try? No.

During the time she wasn’t in pre-school we went from classes in tap, gymnastics, swimming, and tennis (thank you Laura for the thorough schedule) to bike riding around the lake, playing dress up at the Boulder History Museum, and hands on activities at NCAR (National Center for Atmospheric Research), a terrific place for a budding astronaut to explore the effects of gravity. Becoming an astronaut is her passion right now. I promised her she could dance, too, which she wants to do when she’s not in space.

Art projects are part of the game when Grandma is an artist. Even Grandpa Stan got involved with crayons and paper. Cuddles on the couch reading or talking about dinosaurs made quality quiet time. Remember Shel Silverstein’s poems? Laughter all around. Fun!

Time with Sabrina always involves learning new things and improving skills while having fun playing. Did you love to dance as a kid? Do you go dancing now? Take a class or rent a video. Grab a partner or not. It will put a smile on your face. Might even make you laugh. Is dancing not your thing? How about yoga? Get away from your “work” and try something completely different. Read fiction if you always read non-fiction and vice versa. Get in touch with your inner five year old at an art gallery or museum. You’ll see the art differently. Mess around with art materials like you did as a child. I promise I won’t mind the competition.

Grab a child (adult children qualify), grandchild, niece, nephew, brother, sister, spouse, partner, friend, or anyone and share something you’re good at. Right now, Sabrina “helps” me knit. I promised I would teach her how when she’s six, maybe sooner. Grandpa Stan is good with clocks and telling time, also sun, moon and planets. Learn from an almost five year old; be active and inquisitive. Walk the dog, even if you don’t have one. “Live, laugh, love and be happy.”

And, play!

Make your life a work of art.

  • Daniel Feld

    Well done. Like the guest columnist. She’s a good writer! Made me smile.

  • Thanks for leaving a comment, please keep it clean. HTML allowed is strong, code and a href.


President Obama; If You Really Want To Reduce Healthcare Costs, Effectively Reform The Medical Malpractice Tort System: Part 4


Stanley Feld M.D.,FACP,MACE


President Obama, there are other consequences of the present malpractice liability system that cannot measured in dollars or impact. In order to avoid potential law suits physicians are avoiding high risk patients and high risk patient procedures. The result is a decrease in patient access to necessary care.

The measured costs of defensive medicine can be calculated from the Massachusetts Medical Society survey.

“Physicians practice defensive medicine because they don’t trust the medical liability system. This survey should provide a strong impetus for legislative, business, and health care industry initiatives promoting fundamental liability reform.”

It is essential to introduce effective and fundamental liability reform to reduce the practice of defensive medicine, decrease costs and improve access to care.

The Massachusetts Medical Society’s survey of physician concerning defensive medicine also point out the restriction of access to care as a result of the malpractice environment.

“The survey found that 38 percent of responding physicians reported they reduced the number of high-risk services they performed, with orthopedic surgeons (55%), obstetrician/ gynecologists (54%), and general surgeons (48%) reporting the highest frequencies.”

These actions by physicians’ specialties are a natural reaction to the malpractice environment. It also reduces the healthcare system’s capacity to care for sick patients.

“28 percent of physicians in the sample reported reducing the number of high-risk patients they saw, with obstetrician/gynecologists (44%) and the surgical specialties (37–42%) much more likely to reduce their number of high-risk patients.”

In many small or medium sized communities there is little or no access to medical or surgical specialists to take care of high risk patients. President Obama, rather than increase the quality of care, as you have promised, the quality of care in some communities will decrease.

Other surveys by the Massachusetts Medical Society confirm their survey.

“In its annual Physician Workforce Study over the last five years, the Society has found that an average of 44%-48% of physicians in the state reported that they are altering or limiting their practices because of the fear of being sued.”

The 2008 workforce study’s results were worse than the Massachusetts Defensive Medicine survey. More than half of physicians in seven specialties said they have progressively limited their practices, the fear of a frivolous malpractice suit being the primary reason. It is natural for people to adjust to their environment.

“Neurosurgery practices (76%), urology (75%), emergency medicine (66%), obstetrics/gynecology (57%), family medicine (53%), general surgery (51%), and orthopedics (51%).”

President Obama, what should you do to neutralize the negative impact of defensive medicine?

First, do not believe the arguments of the trial lawyers. The claim that malpractice reform will harm patients "by limiting their ability to seek compensation through the courts" is a smoke screen to protect their profitability in law suits.

The medical liability system is inefficient. It does not compensate patients experiencing medical errors very fairly. In fact more than 50 cents on every compensated dollar goes to pay lawyers and the courts. Patients may wait year to receive a single penny. The wear and tear of a malpractice suit on patients experiencing medical errors and physicians being sued is enormous.

The answer is not to leave it up to congress to work it out. Congress has a 30% approval rating. Congress is also composed mostly of lawyers. You are our leader. You are the one who must outline the change that is fair to patients, the government, and physicians.

The fundamentals of change should include the following:

  1. Decrease the profitability of malpractice suits for attorneys.
  2. Invest in a culture of patients’ safety at every healthcare enterprise.
  3. Promote full disclosure to patients about adverse events quickly without legal consequences.
  4. Promote apology to patients without legal consequences.
  5. Provide fair compensation to patients for medical errors.
  6. Professional mediation and arbitration to resolve disputes quickly and dismiss frivolous claims abruptly.
  7. Create a body of judges immune from liability to adjudicate malpractice suits. The body should be composed of physicians and lay leaders. The best judge of physicians medical errors are other physicians if they were freed of adverse countersuit
  8. Create a system of no fault malpractice insurance.
  9. Place limits on patient compensation and expedient rate of compensation.
  10. Eliminate the adversarial nature of the claims.
  11. Build trust between patients and physicians.

Defense attorneys will hate most elements of this proposal because it threatens their vested interest and profitability. I suspect they will fight them with tooth and nail.

President Obama, if you implement these proposals to fundamentally change the medical liability system you would go a long way to reduce the practice of defensive medicine and a yearly wasted cost of $700 billion dollars to the healthcare system.

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


    Woah! I’m really loving the template/theme of this website. It’s simple, yet effective. A lot of times it’s challenging to get that “perfect balance” between usability and visual appearance. I must say you’ve done a fantastic job with this. Additionally, the blog loads extremely fast for me on Internet explorer. Excellent Blog!

  • dallas roofing

    Marvelous, what a website it is! This web site provides useful information to us, keep it up.

  • Thanks for leaving a comment, please keep it clean. HTML allowed is strong, code and a href.


President Obama; If You Really Want To Reduce Healthcare Costs, Effectively Reform The Medical Malpractice Tort System: Part 3


Stanley Feld M.D.,FACP,MACE

President Obama, the details of the Massachusetts Medical Society Defensive Medicine survey have profound importance in explaining trends in the delivery of medical care. Unfortunately, only meaningless sound bites have been given by the media. The survey’s significance has not had the impact on policy it should.

The authors state that the dollar estimates do not include the diagnostic procedures, hospital admissions, specialty referrals and consultations or unnecessary prescription by physicians in specialties not included in the study.

The eight specialties surveyed represent only 46% of the physicians in the Massachusetts. The real costs to the healthcare system from the practice defensive medicine in the state of Massachusetts are much higher. The authors estimate the real costs could be twice the $1.4 billion dollars per year they estimated.

I believe the costs of defensive medicine in many other states are much higher because the cost of litigation in many states is lower and the malpractice awards are higher encouraging litigation.

“This survey clearly shows that the fear of medical liability is a serious burden on health care,” said Dr. Sethi. “The fear of being sued is driving physicians to defensive medicine and dramatically increasing health care costs. This poses a critical issue, as soaring costs are the biggest threat to the success of Massachusetts health reform efforts.”

Defensive medicine is definitely a threat to the success of the Massachusetts healthcare reform efforts. President Obama, defensive medicine is a big burden nationally to the healthcare system. Its costs will undermine any attempt at healthcare reform unless you take medical malpractice liability reform seriously. There has to be a fundamental change in the structure of adjudication.

The survey’s findings must be studied carefully. The physicians surveyed estimated their percentages for defensive medicine testing to avoid law suit. I think their estimates are low. The real percentages must be studied objectively using data mining techniques. Nonetheless the current estimates reveal unsustainable waste in our dysfunctional healthcare system.

Radiological imaging is one tool overused by physicians defensively to avoid litigation. Physicians feel they must test everything even if the probability of a positive result is insignificant.

“Plain Film X-Rays: An average of 22% of X-rays were ordered for defensive reasons.”

“CT Scans: An average of 28% of CT scans were motivated by liability concerns, with major differences among specialties.”

About 33% of scans ordered by obstetricians/ gynecologists, emergency physicians, and family practitioners were done for defensive reasons.

The total number of unnecessary CT scans needs to be calculated along with its costs in order to understand the significance of the percentage presented. The health policy solution should not be to lower the reimbursement for CT scans. The solution is to fix the medical malpractice liability system.

MRI Studies: An average of 27% of MRIs were ordered for defensive reasons, with significant differences by specialty.

The highest rates were reported by obstetricians/ gynecologists, general surgeons, and family practitioners, with the lowest rates by neurosurgeons and emergency physicians.

Ultrasound Studies: An average of 24% of Ultrasounds were ordered for defensive reasons. Orthopedic surgeons (33%) and obstetricians/gynecologists (28%) reported the highest rates, with neurosurgeons (6%) and anesthesiologists (9%) the lowest.

I believe neurosurgeons are underestimating their use of radiologic procedures in order to look good. Neurosurgery is one of the specialties with the highest malpractice rates. Please note that obstetricians/gynecologists take no chances and order the most procedures for defensive purposes.

Laboratory Testing:

An average of 18% of laboratory tests were ordered for defensive reasons, with emergency physicians (25%) reporting the highest rates and neurosurgeons (7%) the lowest.

Specialty referrals, consultations and hospitalizations are overused the most for defensive reasons. No one wants to take a chance and send the patient home even if the indication for hospitalization is small. Hospitalization is also the most costly overused element in defensive medicine.

Specialty Referrals and Consultations:

“An average of 28% of specialty referrals and consultations were motivated by liability concerns, with significant differences by specialty. Obstetricians/gynecologists reported that 40% of their referrals and consultations were done for defensive reasons, and anesthesiologists and family practitioners said that 33% of their referrals and consultations were done for the same reasons.”

Hospital Admissions:

An average of 13% of hospital admissions were motivated by liability concerns, with surgical specialties reporting lower rates than the other specialties.

The percentages of defensive procedures are admitted by practicing physicians. The cost of defensive medicine is high and wasteful. President Obama, defensive medicine is not the minor problem that the malpractice attorneys want you to believe it is. It is time for definitive action now.


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

  • Medical Negligence 

    The doctor’s actions have caused or contributed to the plaintiff’s personal injury, his actions may not be deemed negligent if it can be shown that they were the ‘reasonable’ actions of a medical professional given the information the doctor had and the specific circumstances.

  • Tyler grey

    I just stumbled upon your informative blog and wanted to say that I have really enjoyed reading your blog posts. I will be your frequent visitor.

  • Thanks for leaving a comment, please keep it clean. HTML allowed is strong, code and a href.


President Obama; If You Really Want To Reduce Healthcare Costs, Effectively Reform The Medical Malpractice Tort System: Part 2

Stanley Feld M.D.,FACP,MACE


President Obama, as you know the real truth is elusive. Every vested interest has an agenda to protect. My agenda as a long time practicing Clinical Endocrinologist, now retired from active practice, has been to preserve the value of the profession of medicine and permit the delivery of the best clinical care possible to patients. Society has strayed from these goals. There are multiple problems with the healthcare system. They are interrelated and must be solved simultaneously.

The present malpractice liability problem leading to the practice of defensive medicine is a huge problem for the healthcare system. It is essential that this problem be solved before meaningful cost savings and increased quality of care are realized

Malpractice attorneys dismiss the system of adjudicating malpractice liability as the cause of significant defensive medicine costs. They claim that they are the protectors of mistreated patients. You will soon receive a 29 page document defending their claim and dismissing the significance of defensive medicine.

“Trial lawyers are preparing for a fight, starting with a 29-page research document they will send to Capitol Hill in an attempt to convince lawmakers that lawsuits have very little to do with healthcare costs.”

The malpractice attorneys will attempt to make a compelling argument. I suspect they will have little real scientific evidence to prove their point in the 29 page document.

Donald Berwick Professor in the Department of Health Policy and Management Department of Health Policy and Management has never been a friend of practicing physicians. He has frequently pointed out the defects in the practice of medicine. Recently Don Berwick made the following off the cuff comment in response to a question after he addressed the American Medical Association (AMA) meeting.

"What about malpractice reform?" the first questioner asked when Berwick opened up the discussion to attendees. He was a physician, and murmurs of approval rippled through the crowd.”

Berwick’s answer didn’t please the questioner and many of his colleagues. “The data just doesn’t back up the claim that malpractice lawsuits are one of the top drivers of healthcare costs, he replied.”

No one was brave enough to ask Dr. Berwick to show them the data for this conclusion. I have read Fooled By Randomness twice. I am starting to understand that all expert opinions are noise unless they are confirmed scientifically. Even then conclusions can change as the knowledge base changes.

In November 2008, the Massachusetts Medical Society published a survey of practicing physicians. The purpose of the survey was to get a sense of what practicing physicians (the generators of defensive medicine) thought the incidence of defensive medicine was in their practice. I was surprised it was not published in the New England Journal of Medicine.

“A first-of-its-kind survey of physicians by the Massachusetts Medical Society on the practice of “defensive medicine” – tests, procedures, referrals, hospitalizations, or prescriptions ordered by physicians out of the fear of being sued – has shown that the practice is widespread and adds billions of dollars to the cost of health care in the Commonwealth.”

The devil is usually in the details. The details found were the details at ground level. It was not speculations by experts or secondary measurement. The defect in the survey was the fact that was a survey (surveys have its scientific defects) even though 900 practicing physicians in eight specialties in Massachusetts completed the survey. Its strength is the survey links practice to costs.

“The Investigation of Defensive Medicine in Massachusetts” is the first study of its kind to specifically quantify defensive practices across a wide spectrum and among a number of specialties. The study is also the first of its kind to link such data directly with Medicare cost data.”

Physicians self reported on seven tests that might be used in defensive medicine. They were plain film X-rays, CT Scans, Magnetic Resonance Imaging (MRIs), ultrasounds, laboratory testing, specialty referrals and consultations.

Based on Medicare reimbursements rates in Massachusetts for 2005-2006 the eight specialties surveyed generated 281 million dollars in defensive medicine costs in outpatient clinics. Their practice of defensive medicine also generated $1.1 billion in unnecessary costs for hospital admissions. The big winner here was the hospitals. Hospitals might not be motivated to fight as hard as physicians to eliminate defensive medicine because defensive medicine serves its revenue generating agenda well.

The estimate of a total of $1.4 billion only includes 7 tests and 8 specialties in a 900 physician sample. Massachusetts is a small state. If we assume all the states are the same size and multiple by 50 states we are talking about $70 billion dollars wasted on defensive medicine.

If the survey included all specialties, all physicians, and all costs including the cost of malpractice premiums and physician practice time lost in litigation in all states, my guess would be the cost of defensive medicine would be ten times the 70 billion dollars. A $700 billion dollar cost for defensive medicine is an unnecessary cost to the healthcare system. This cost can be dismissed lightly or yield to unscientific expert opinion. The result does not include the emotional toll on physicians being sued and the lawsuits effect on their ability to practice medicine.

The legal system for handling malpractice claim is very costly. A more logical and cost effective system for adjudicating patients harmed by medical error needs to be instituted.

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

  • Thanks for leaving a comment, please keep it clean. HTML allowed is strong, code and a href.


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

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.

  • Ted Howard

    My girlfriend is a first year ER resident. She recently did her cardiology rotation. She admitted the same homeless crack addict three times in one week because his chest hurt and his triponin was elevated. Those are symptoms of his crack smoking, not an MI. They had to admit three times before they could start telling the ER that they refused to admit him. The hospital was his hotel. He paid his bills with unspoken threats of malpractice claims, threats he didn’t even know he was making.
    Seen this?

  • Thanks for leaving a comment, please keep it clean. HTML allowed is strong, code and a href.


Father-Son Weekend Part 2

Stanley Feld M.D.,FACP,MACE

This is about two pals, a father and son, hanging out for a weekend, bonding, learning from each other and eating stuff we would never eat at home.

Brad flew from Los Angeles to San Francisco Friday morning to visit one of his companies. He left L.A. at 7 am and was back at 2 pm. We met for lunch at Carney’s ,a famous Hamburger/Hot Dog joint on Sunset Strip. The yellow train on Sunset Blvd is cool but the hot dogs and hamburgers are overrated.

After lunch we were both sleepy. We went to our room at the Mondrian Hotel and took the now famous Feld nap. My father invented it. My brother, Charlie, and I perfected it. Brad, his brother, and two cousins are taking it to the next level. It is as things should progress.

We blew off a scheduled dinner downtown at Water Grill. The guys we were to meet got sick and cancelled. Brad and I walked along Sunset Strip to observe the beautiful people. There are also plenty of beautiful people at the Mondrian Sky Bar and the Pool Deck. It is a happening place.

During our walk we stopped at “Ketchup” for dinner. Its sign was cool. We were lucky to get a table after promising to eat fast. “Ketcup” was funky and unusual. They have a great menu for 20 to 35 year olds. The mac and cheese with five different flavors of ketchup was up there with the best. We talked two girls sitting at the next table into ordering it.

We had chocolate gelato at Café Pisano. After gelato Brad and I started to walk. We had a deep philosophical discussion. I love talking philosophy with Brad. These days I learn much more than I teach.

We continued down Sunset Set Strip until we got tired mentally and physically. A great kind of tired. Before retiring we needed a little more Mondrian Pool Deck.

The next morning I ran 3 miles. I was back without quadriceps pain. We had a breakfast meeting scheduled with Dov Seidman. I referred to Dov in a blog last week. Brad and Dov are good friends. Dov is one smart guy. He is a humanist. One of his views is the economic crisis is going to change society for the better. We will once again become human beings rather than human doers.

The healthcare industry needs some humanization.

The amazing thing to me is Brad and Dov’s generation have a broader view of the world and human potential than most of the group running the country. We sat and talked for two hours. Both of them ended up teaching me a lot.

Jason Mendelsohn and Ryan McIntyre told Brad that Pizzeria Mozza was the best pizza in the world. We took a cab to Pizzeria Mozza. The crazy thing about L.A. is that every cab ride is $30 or more. Traffic is everywhere. Brad’s IPhone has a link to calling a cab by email. His Iphone GPS tells us where the traffic jams are. Since the jams are everywhere it didn’t help much.

We got to Pizzeria Mozza at 11 am. They do not open until 12 pm. So we walked about 3 miles down Melrose just talking. The conversation was invigorating. Jason was correct. It is great pizza. I remember my first date with Cecelia 50 years ago. We had pizza is a hole in the wall on Boston Post Road and Gunhill Road in the Bronx run by an Italian family. Today’s pizza is the only one that matched that pizza. My recollection could be clouded by love at first sight.

I wanted to see the Contemporary Museum of Art and the L.A. Symphony Hall. Another $30 cab ride without air conditioning. The museum’s permanent collect was fabulous. It has a Rothko room that is as good as the Rothko Chapel in Houston. I thought the Dan Bradberry exhibit was mediocre.

Frank Gehry’s Symphony Hall was cool but not his best work. Bilbao is better.

There were no cabs in downtown L.A. on Saturday afternoon. We walked two miles to Oblong’s office for a demonstration from John Offenkopper. He and Kevin Parent (cofounders) were Brad’s fraternity brothers at MIT. So many kids in that fraternity were so smart.

John was Stephen Spielberg’s technical adviser in “The Minority Report”. He converted the fantasy into reality. Children born in 2010 will not have heard of a keyboard and a mouse is just as my granddaughter has not heard of a typewriter. They will be replaced by finger and hand motions.

Marty drove downtown to see the Oblong demonstration. He drove brad and me to the Mondrian. (I appreciate the fact that it was out of his way). The Feld guys needed a nap but we had cancelled our reservation for 7pm at Asiadecuba. We figured we ought to try to get a table at the pool at 6 pm. What a scene! The meal was also good. We were so sleepy after dinner. We slept from 8 pm to 7 am Sunday. I haven’t slept 11 hours straight in 40 years. .

Mark Suster twittered Brad on Saturday and asked if he could meet us for breakfast on Sunday. Brad did not know Mark. Brad googled him on his Iphone. He then twittered him a yes at the Mondrian Asia Cuba at 8.30 a.m. It is an instant world out there folks.

The breakfast meeting was wonderful. Again I learned how things are done in the New World. I got on the airplane again invigorated by a wonderful weekend of just hanging out with my son.

Next is a weekend with Daniel. We are just waiting for him to pick the weekend.


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

  • Thanks for leaving a comment, please keep it clean. HTML allowed is strong, code and a href.


Father Son Weekend: First Two Days With My Medical School Roomate


Stanley Feld M.D.,FACP,MACE

My father –son weekend this year with Brad was in Los Angeles.

We picked Los Angeles because L.A. is warm in March and Brad has invested in Oblong Inc. an L.A. company co-founded by John Underkofflerer and Kevin Parent. They are two great guys I met when Brad was at MIT. 

My 50th Columbia College reunion is coming up in June . I volunteered to be on the Jubilee Reunion committee. As a member of the reunion committee I developed a social network for Columbia College CC’59 using Ning. I like Ning’s founder Marc Andreesen’s mind. I was curious to see if a social network would work with 70 year old Columbia College graduates. We all need social networks because we are all social beings whether we admit it or not. .

The network works. I have reconnected with college friends I have not seen in 50 years. One connection was with one of my medical school roommates.

He invited me to visit him when I was in L.A.(Santa Monica) . I went to Los Angeles two days before my weekend with Brad to renew our friendship. The first challenge was getting to his house and then getting into his house. The taxi dropped me off a block from his house because a gate closed off his street. I snuck through the gate

Marty is a psychiatrist. He sees patients in his house. He office layout is the same as HBO’s program “In Treatment”. I arrived early and figured he would be busy with a patient. I was sure he would leave a window open to climb in just as he did in our basement apartment in medical school. Lucky for me I arrived during his lunch break . He has two Great Danes. Each one is bigger and heavier that I am. If I climbed through the window I would have been the Great Danes’ lunch.

Marty and I had a simple lunch and talked non-stop. He cancelled his patients for the rest of the day. We were off to his gym. I jog daily. I never used an elliptical machine although Cecelia has tried to convince me to try it. Marty insisted I use it because then we could talk side by side. After 15 minutes my quadriceps were on fire. When I got off the machine (after 35 minutes), I could hardly stand up. It felt seasick for the next hour.

In our gym clothes we went galley hopping at Bergamot Station in Santa Monica. When we got back to his home he asked me to help him walk his Great Danes.

I am not a dog lover. The dog I was walking almost dislocated my shoulder. It was less than an enjoyable experience.

Marty has not changed one bit in 50 years. I would bet most of us haven’t changed much.

Dinner and an investment meeting in the fancy Shutter Hotel on Santa Monica beach. The meeting confirmed my impression of economic market predictions. Everyone should read “Fooled by Randomness”.

With my thighs still hurting I ended up running 4 miles to the Santa Monica Pier by myself the next morning. My run to the Pier was too much. My thighs were really hurting now. I had to run walk or crawl to get back since I had no money.

Marty and Francine took me for a surprise lunch of Hebrew National Hot Dogs at Costco I love Costco. The three of us went shopping and spent an hour buying things they did not need.

Next, L.A. Louver Art Gallery in Venice. It was wonderful. The David Hockney prints on exhibit were a mind blowing experience.

Brad and John were to meet us at 7 pm at Cholada Thai cusine on Malibu Beach.

They do not take reservations. However, Marty using his best psychiatric skills and charm talked them into giving us a reservation for 7 pm. Brad and John were stuck in traffic. Brad twittered me their problem. We gave up our table and walked on the beach until they showed up. Welcome to L.A.The meal was great and the look of the place was authentic hippy.

On Friday morning we went to the L.A . Museum of Art . The museum architecture is hodge podge. I think L.A. county should have blown up the original build before adding on. The exhibits were fair.

Norman Cousins said laughing is good for your health. I had two day of reminiscing and continuous laughing or smiling. Marty dropped me off at the Mondrian Hotel to meet up with Brad.

Thank you Marty and Francine for showing me the Los Angeles I had never seen before. And finally thank you Marc Andreesen for Ning and reconnecting me to Marty.

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

  • Thanks for leaving a comment, please keep it clean. HTML allowed is strong, code and a href.