The health care crowd is abuzz with The New York Times revelation that Medicare billing rates seem to have increased by billions of dollars in parallel with increased adoption of EHR technologies for both hospitals and ambulatory services. The culprit for this unexpected increase is the measly E&M code. Evaluation and Management (E&M) is the portion of a medical visit where the doctor listens to your description of the problem, takes a history of previous medical issues, inquires about relatives that suffered from various ailments, asks about social habits and circumstances, lets you describe your symptoms as they affect your various body parts, examines your persona and proceeds with diagnosing and treating the condition that brought you to his/her office or hospital.

The more thorough this evaluation and management activity was, and the more complicated your problem is, and the more diagnostic tests are reviewed, and the more counseling the doctor gives you, the more money Medicare and all other insurers will pay your doctor. Makes perfect sense, doesn’t it?

In 1995 and again in 1997 Medicare has specified exactly how to measure a doctor’s thoroughness by creating 5 levels of visits and defining each level’s complexity in terms of an exact number of questions a doctor asks, and an exact number of organs and body parts that are addressed during a visit. The more sanctioned questions and body parts are addressed, the more money the doctor gets from the payer. During the olden paper days, no physician in his right mind would go to the trouble of actually writing down all these largely irrelevant things, and since Medicare always threatened to audit physician billings, most doctors practiced “defensive billing” and consistently charged less than they should have, because the hand written documentation was rarely indicative of the actual level of service. Enter Electronic Medical Records.

Since before the HITECH act and before the Meaningful Use epidemic, EHR vendors promised doctors an automated way of documenting a visit, so they can spend more time with the patient and not have to constantly write things down. Instead, a click on a couple of boxes would do that for them. Furthermore, physicians won’t have to waste money on expert coders to go through their scribbled notes and figure out a visit level. The software will automatically calculate the appropriate E&M code, based on boxes clicked. Structured data can be very useful for calculations. To make the entire process most efficient, three methods of documentation have been developed to replace hand writing and to efficiently minimize the need for extensive box-clicking.

  • Documentation by Exception – Every EHR has this “feature” allowing the documenter to click on ONE box usually at the top of the page which generates a professional sounding clinical sentence for each organ or body part stating that everything is perfectly normal, or that all your histories are unremarkable in any way. This is a great efficiency to be applied presumably after the interviewer ascertained that all is well with your past and present relatives and body parts. If something is wrong with one or two organs, the clinician can click the Normal button and then edit the exceptional few organs that are affected today, thus obtaining documentation for a complete review or examination of all your systems. Remember that every organ and family member documented is worth a few more dollars according to Medicare’s fee-for-documentation model of reimbursement. No wonder then that this is now a basic feature in every EHR.
  • Pre-filled Templates – These go by different names, but they are a huge time saver for simple and common problems and here is how they work: Let’s say you see a patient with an URI and it is flu season. You document the visit de novo starting from a blank URI template, use all the previously described efficiencies and generate a lovely visit note for this patient. It then dawns on you that you are likely to see hundreds of similar patients in the months to come, and that you always go about these things the same way asking the same questions and getting the same answers. You can save this visit note as a pre-filled template sans patient demographics and histories (really just the HPI, ROS, Exam and for the brave also Assessment and Plan) and when the next URI patient shows up, you can load this pre-filled template and edit exceptions, if any. Since technology is magical, EHRs will also load the patient specific histories and merge them into your brand new note automatically. Two or three clicks will get you enough documentation to allow your EHR to calculate a very nice E&M code and generate enough documentation to keep the payers at bay.
  • Bring Forward – This is really sweet for complex patients with chronic disease that come to see you every few months or so. We all know that not much changes in a few months and most likely everything you will be documenting today is exactly what you documented six months ago. Instead of starting from scratch every time, EHRs have created great efficiency by making it possible for the documenter to bring forward, or load, the previous visit note and allow him/her to edit and make changes based on today’s visit. This beats the old “copy & paste” by a mile, and with a click of a button you have all the organs and relatives and complexity of decision making documented in minute detail. You can now make a few changes here and there as necessary, and the EHR will calculate the appropriate E&M code.

There are other features in most EHRs that are designed to improve reimbursement, but these are the most popular. There are also administrative functions embedded in larger EHRs that allow those who employ physicians to ensure that the docs click on all the necessary things to ensure optimal billing and payment. It is very easy to be critical of clinicians in these scenarios, but let’s remember that if Medicare wouldn’t have defined the value of a doctor visit to be proportional to the amount of text generated during the visit, none of this would have happened.

So the “unintended consequences” of pushing physicians to use EHRs seem to consist of doctors actually using EHRs, as effectively as possible, to document all the little details Medicare wants to see. This can only surprise people who had no clue what EHRs are, how they work, and how they are used in everyday practice, which did not (does not) prevent said people from proclaiming themselves as health care experts, best suited to set the national agenda for EHR design and adoption.

Bonus Tip: Now that everybody has been properly shocked by the E&M coding efficiency introduced by EHRs, I would suggest examining the efficiencies introduced by the variety of “smart” order-sets.

Margalit Gur-Arie was COO at GenesysMD (Purkinje), an HIT company focusing on web based EHR/PMS and billing services for physicians. Prior to GenesysMD, Margalit was Director of Product Management at Essence/Purkinje and HIT Consultant for SSM Healthcare, a large non-profit hospital organization. She shares her thoughts about HIT topics and issues at her blog, On Healthcare Technology.

Share on Twitter

44 Responses for “Shock and Awe: EHRs Work as Designed”

  1. Legacy Flyer says:

    In essence the Feds have been “hoist with their own petard”

  2. southern doc says:

    Ms. Gur-Arie hits another one out of the park. Great post!

    • BobbyG says:

      Indeed. Tweeted and cited.

      ” Every EHR has this “feature” allowing the documenter to click on ONE box usually at the top of the page which generates a professional sounding clinical sentence for each organ or body part stating that everything is perfectly normal, or that all your histories are unremarkable in any way.”

      That has always bothered me. NO ONE falls for that mechanical SOAP “narrative.”

  3. bird says:

    Great Post, Perfect timing, Just had a lecture from legal stating that docs are now going to be targeted by CMS if you use templates, carry forwards, copy and paste. I have never forgotten the article quoting Jonathon Bush ceo of an ehr company stating that the EHR is all about control. I think we are seeing that now more then ever.

  4. rbaer says:

    In my experience, this is only half true.
    -for the ROS, it is sufficient to document that “the remainder of a complete ROS is negative”. I usually ask questions to cover all systems, but I doubt every doc does. In other words, you don’t need EMR to document a lot in a wink
    -a lot of complexity is actually based on decision making – for instance, prescription medication counts more than “take an aspirine’ but less than “we need to get you to an ER/OR for surgery right away”.
    -cognitive medicine is relatively underpaid, depending on the situation and payor (e.g. medicare vs medicaid), it is somewhat understandable that physicians want to upcode, also considering that a cognitive eval may go along with various unpaid services (answering telephone/Email questions, refills, forms).
    -it is in general very hard to deduct easily from a note what the provider did and how much time he/she spent (a doctor usually can, but there is subjectivity to it). One can easily blow up a note, so word count would not help, and the codes – in a somwhat clumsy and complicated way – try to address what a physician actually did. Time based billing is not an option because some patients and docs would engage in endless chatter, maybe pleasant and stress reducing for both patient and doc, but economically not viable.

  5. Leo says:

    Yes, shocking, people and their technologies document and do what you pay them to document and do. Technology always has the potential to accelerate dumb practices. Incentives are the culprit. Technology only does what you ask it to, and usually, that involves trying to make more money or save time, or both. When we ask technology to improve health rather than increase billing, it will do that, too.

  6. steve says:

    Is part of our problem implementing EHRs a reflection of how far the medical industry lags in general IT adoption. As aprt of a project to get EHRs working for our group, I found out that none of the hospitals in our network or in our area, and none of the surgicenters even collect email addresses from patients. All communication is by phone or snail mail. Does this sound like a problem to anyone else?

    Steve

  7. J.T. says:

    Is it any shock that during this grand EMR rollout with FFS still present in most of the payment system that services billed would increase (the original function of most legacy EHR systems was for billing, duh)? We will only be able to judge the efficacy of these systems for cost-control after both the public and private sectors stomp out FFS and institute quality based reimbursement systems with radically different incentives.

  8. Bobbi says:

    I have audited 1,000s of MD records (defensively) and these templates are often used effectively. But, they are also a dead giveaway when someone is just clicking all of the boxes—for example, a physical statement reads that the “breasts were palpated for lumps” when the patient has had a double mastectomy in their history. Further, the weight of Medicare’s payment law rests on medical necessity. If the patient comes in and their condition or complaint list has not changed materially, there is no grounds to bill for a higher level code, no matter what template you use or how many boxes you check.

    • I don’t think doctors are using these features to commit fraud. I think they are using them to support claims for more realistic levels of payments.
      There are always exceptions, of course….

      • Bobbi says:

        I don’t think they are either (except those that generate charges for no patient at all). But, because the E/M code requirements are so dependent on numbers of systems and such, they believe that checking each box entitles them to a higher level visit and that is just not true. But, the AMA and CMS have done a poor job of communicating that.

  9. rbaer, obviously not everything is applicable to every situation, but the templated note has made generating, counting and calculating infinitely easier. Add to that boxes that you can check for complexity of decision making, tracking of diagnoses addressed, tracking of labs reviewed, box for >50% counseling, etc. and you have a perfect E&M machine, which not only calculates an appropriate level, but also maintains supporting documentation for posterity.

    Personally, I don’t see anything wrong with that. I am thrilled to see that EHRs delivered on their main selling point and as Leo said, now let’s ask for something else and see if they deliver. The problem is that your hospital (or whoever writes the check) will have to ask for these things. Do you thing anybody is asking technology to “improve health” at this time?
    Patients may, but patients are not directly paying for technology….

    As to time based payment, I find it depressing that Medicare (and all other payers) cannot just accept physicians’ assessment of what he/she should be paid for a visit. I don’t think folks would just chat endlessly if the payment was time based. Lawyers don’t, and this is as easily audited as the insane E&M schemes.

    • rbaer says:

      Do you have an idea for how many people seeing the provider is either a. a social outing or b. a situation associated with secondary gain? And of coursr its easier and more pleasant to see 10 patients and chat i/o 20 and rush from one to the next.

      • Yes, I do. I have seen elderly and lonely folks make appointments with PCPs just so they can talk to someone. The mostly geriatric practices where I observed this thought that was a nice thing to do (no, they weren’t looking for extra money), and so do I. Certainly beats antidepressants or worse.

        I’m sure it’s more pleasant to see 10 patients thoroughly than it is to see 20 or 30 or whatever… I don’t see anything wrong with that either. Isn’t this exactly why Dr. Rob is stepping outside the system? If it’s so much better, why not make the system work that way too? Primary care is not that expensive….

        • rbaer says:

          “I’m sure it’s more pleasant to see 10 patients thoroughly than it is to see 20 or 30 or whatever… I don’t see anything wrong with that either.”

          As long as many people lack access to care, we have to use physician time wisely. In ideal world, agree that it would be nice to do your work without time constraints.

  10. DrK says:

    It is accounting software that has delivered on the ROI statements made by those selling EMRs. The problem is not the software or the doc using it, it is the way we are paid.

    Let’s move these EMRs away from digitalizing a progress note and more towards population management tools which are in line with the new payment mechanisms being developed.

  11. Dr says:

    Reading this on the other side of the Atlantic is very strange. It seems that BIG BUSINESS has finally landed the coup de grace on the way you deliver healthcare out there. Finally doctors can work in the same way as accountants do. Every box ticked either manually or by default results in the reassuring CHING-CHING of the cash register. Doctors can now FEEL the money flow into their veins while actually practicing, giving them the necessary fillip to deal with the very important bureaucracy required by the professional accountants working for the all important insurance companies.

    Alas, this technology will not improve your healthcare per capita rating in the world. The USA stands at 37th in the world (not bad not bad there are 100s of countries in the world you know) in this regard (If you don’t believe me read the NEJM of Jan 2010) with every chance of moving into the 40s. Still you do offer the ‘best medicine money can buy’ and as far as medicine is concerned, it is still the best place in the world to live – for doctors! As for the customers, I mean patients, well things are not quite as rosy but hey, blame that on your founding fathers: They were the ones who left universal health care out of the Constitution and for that they receive songs of praise from all your doctors, medical insurance companies and of course Big Pharma. But what can you do? Any alternative to this is communism, isn’t it?

  12. John Ballard says:

    Here’s an oncologist who likes the new technology.

    This is just the beginning. Although EMRs now provide assistance with basic medical care, such as scheduling flu shots, identifying drug interactions, and health screening reminders, future systems will use academic information to assist the doctor in making diagnoses and planning treatments. Seamless with the EMR will be computer augmentation to create differential diagnoses and recommend treatment alternatives. In oncology alone there are almost 50,000 articles published each year; Artificial intelligence integration with the clinical EMR will help every doctor penetrate that massive database on a continuous basis as it applies to individual patients.

    http://sunriserounds.com/?p=899

  13. pcb says:

    ” Seamless with the EMR will be computer augmentation to create differential diagnoses and recommend treatment alternatives. In oncology alone there are almost 50,000 articles published each year; Artificial intelligence integration with the clinical EMR will help every doctor penetrate that massive database on a continuous basis as it applies to individual patients”

    What percentage of those 50,000 articles are reliable studies that give us useful information that should influence clinical decision making? Are we hoping the “artificial intelligence integration with the clinical EMR” will help us sort that out by “penetrating the database?”
    And what about patient preferences and values?

    Garbage in……..

    • BobbyG says:

      apropos?

      “A culture of denial subverts the health care system from its foundation. The foundation—the basis for deciding what care each patient individually needs—is connecting patient data to medical knowledge. That foundation, and the processes of care resting upon it, are built by the fallible minds of physicians. A new, secure foundation requires two elements external to the mind: electronic information tools and standards of care for managing clinical information.

      Electronic information tools are now widely discussed, but the tools depend on standards of care that are still widely ignored. The necessary standards for managing clinical information are analogous to accounting standards for managing financial information. If businesses were permitted to operate without accounting standards, the entire economy would be crippled. That is the condition in which the $2½ trillion U.S. health care system finds itself—crippled by lack of standards of care for managing clinical information. The system persists in a state of denial about the disorder that our own minds create, and that the missing standards of care would expose.

      This pervasive disorder begins at the system’s foundation. Contrary to what the public is asked to believe, physicians are not educated to connect patient data with medical knowledge safely and effectively. Rather than building that secure foundation for decisions, physicians are educated to do the opposite—to rely on personal knowledge and judgment—in denial of the need for external standards and tools. Medical decision making thus lacks the order, transparency and power that enforcing external standards and tools would bring about.”

      “… [C]urrent policy fails to comprehend the needed discipline in medical practice and thus fails to define precisely what is needed from health information technology. A dangerous paradox thus exists: the power of technology to access information without limits magnifies the very problem of information overload that the technology is expected to solve. Solving that problem demands a meticulous, highly organized, explicit process of initial information processing, followed by careful problem definition, planning, execution, feedback, and corrective action over time, all documented under strict medical accounting standards. When this rigor is enforced, a promising paradox occurs: clarity emerges from complexity.

      No such relief from complexity is in sight now. A wide gap exists between current reform initiatives and the disciplined medical practice that patients need. This gap exists regardless of whether health care is public or private, and regardless of whether health care spending is provider-driven (traditional fee-for-service medicine), payer-driven (managed care) or now “consumer-driven.” Until the gap is closed, attempts at cost control and quality improvement will continue to revolve in a circle, without sustainable progress.

      In contrast, were we to close the gap between medical practice and patient needs, society then could find enormous opportunities to harvest resources now going to waste. These wasted resources include not only vast sums spent on low-value care but also a vast body of medical knowledge that all patients and practitioners could use more effectively, simple tests and observations that in combination could uncover solutions to patient problems, patients who could become better equipped and motivated to improve their own health behaviors, routine patient care that could become a fertile source of new medical knowledge, and the firsthand insights of practitioners and patients who could participate in harvesting that new knowledge for their own benefit.
      __

      - Lawrence Weed, MD and Lincoln Weed, PhD, “Medicine in Denial”

      • BobbyG says:

        Related:

        http://healthaffairs.org/blog/2012/09/25/an-evidence-based-approach-to-communicating-health-care-evidence-to-patients/print/

        “It has been 22 years since David M. Eddy—the heart surgeon turned mathematician and health care economist—put the term “evidence-based” into play with a series of articles on practice guidelines for the Journal of the American Medical Association.

        But as we have learned in the years since, one person’s evidence-based guideline is another person’s cookbook. For some, a sound body of evidence is fundamental to sound medical decisions. After all, as Jack Wennberg and Dartmouth researchers have pointed out for decades, if the practice of medicine varies so widely from place to place in this country, everyone can’t be right. Yet for others, evidence connotes not just “cookie-cutter medicine,” it is only one step shy of a trip to the death panel. This heavy baggage influences the way evidence-based medicine is discussed from the doctor’s office to the clinic to Capitol Hill…”

  14. Gwen says:

    While technology is continually evolving, such as the advancement of EHRs, how it is utilized is up to the person. There are obviously many pros to utilizing EHRs – basic things such as providing efficient care in a timely manner and improving patient flow, whether it’s documenting by exeption, or using pre-filled templates. However, when used improperly, EHR does not serve it’s main purpose, which is to provide the best quality of patient care. Like Leo said, despite the advancement in technologies such as in health care, how they are utilized by health care providers is what really matters.

  15. pcb says:

    “A dangerous paradox thus exists: the power of technology to access information without limits magnifies the very problem of information overload that the technology is expected to solve. Solving that problem demands a meticulous, highly organized, explicit process of initial information processing, followed by careful problem definition, planning, execution, feedback, and corrective action over time, all documented under strict medical accounting standards. When this rigor is enforced, a promising paradox occurs: clarity emerges from complexity.”

    I wish I had read this before. It’s all becoming clear…… clarity of patient care can emerge from complexity, if I just follow a meticulous, highly organized, explicit process of information processing, follwed by careful problem definition, planning, execution, feedback, and corrective action over time, all documented under strict accounting standards.

    That sounds great. Sign me up.

  16. pcb says:

    wait….., what, clarity, meticulous highly organized, complexity, information processing, problem definition, accounting standards.

    what were we talking about again?

  17. Regarding the Health Affairs article:
    I’m struggling with the label “evidence-based” medicine…. What is the alternative? Non evidence-based? Guess work? Making stuff up as you go?
    What is evidence? Is education or experience a type of evidence? Is there zero bias when other types of evidence are created? Is it possible to have conflicting evidence? Should all evidence be considered equal? Is new evidence better than old evidence? Always? Sometimes? Are we saying that all people would act in the same way, if exposed to the same evidence? Is professional judgement not required if we have evidence?
    Or is practicing evidenced-based medicine mean that the practitioner is accepting the interpretation of evidence by whoever is in charge of making the rules?

    I understand that eventually evidence will become deterministic, but it isn’t so now, so I don’t see the benefits of creating a single point of massive failure by arbitrarily delegating interpretation of evidence to a regulatory body, and dismissing millions of more experienced, equally learned and equally educated interpretations.

    • BobbyG says:

      Several decades ago, written by surgeon and writer Dr. Richard Selzer:

      “On the bulletin board in the front hall of the hospital where I work, there appeared an announcement. “Yeshi Dhonden,” it read, “will make rounds at six o’clock on the morning of June 10.” The particulars were then given, followed by a notation: “Yeshi Dhonden is personal physician to the Dalai Lama.” I am not so leathery a skeptic that I would knowingly ignore an emissary from the gods. Not only might such sangfroid be inimical to one’s earthly well-being, it could take care of eternity as well. Thus, on the morning of June 10, I joined a clutch of whitecoats waiting in the small conference room adjacent to the ward selected for the rounds. The air in the room is heavy with ill concealed dubiety and suspicion of bamboozlement. At precisely 6 o’clock, he materializes, a short, golden, barrely man dressed in a sleeveless robe of saffron and maroon. His scalp is shaven, and the only visible hair is a scanty black line each hooded eye.

      He bows in greeting while his young interpreter makes the introduction. Yeshi Dhonden, we are told will examine a patient selected by a member of the staff. The diagnosis is as unknown to Yeshi Dhonden as it is to us. The examination of the patient will take place in our presence, after which we will reconvene in the conference room where Yeshi Dhonden will discuss the case. We are further informed that for the past two hours Yeshi Dhonden has purified himself by bathing, fasting, and prayer. I, having breakfasted well, performed only the most desultory of ablutions, and given no thought at all to my soul, glanced furtively at my fellows. Suddenly, we seem a soiled, uncouth lot.

      The patient had been awakened early and told that she was to be examined by a foreign doctor, and had been asked to produce a fresh specimen of urine, so when we enter her room, the woman shows no surprise. She has long ago taken on that mixture of compliance and resignation that is that the facies of chronic illness. This was to be but another in an endless series of tests and examinations. Yeshi Dhonden steps to the bedside while the rest stand apart, watching. For a long time he gazes at the woman, favoring no part of her body with his eyes, but seeming to fix his glance at a place just above her supine form. I, too, study her. No physical sign nor obvious symptom gives a clue to the nature of her disease.

      At last he takes her hand, raising it in both of his own. Now he bends over the bed in a kind of crouching stance, his head drawn down into the collar of his robe. His eyes are closed as he feels for her pulse. In a moment he has found the spot, and for the next half hour he remains of us, suspended above the patient like some exotic golden bird with folded wings, holding the pulse of the woman beneath his fingers, cradling her hand in his. All the power of the man seems to have been drawn down into this one purpose. It is tell patient of the pulse raced to the state of ritual. From the foot of the bed, where I stand, it is as though he and the patient had entered a special place of isolation, of apartness, about which a vacancy hovers, and across which no violation is possible. After a moment the woman rests back upon her pillow. From time to time she raises her head to look at the strange figure above her, then sinks back once more. I cannot see their hands joined in a correspondence that is exclusive, intimate, his fingertips receiving the voice of her sick body through the rhythm and throb she offers at her wrist. All at once I am envious — not of him, not of Yeshi Dhonden for his gift of beauty in holiness, but of her. I want to be held like that, touched so, received. And I know that I, who have palpated 100,000 pulses, have not felt a single one.

      At last Yeshi Dhonden straightens, gently places the woman’s hand upon the bed, and steps back. The interpreter produces a small wooden bowl into sticks. Yeshi Dhonden pours a portion of the urine specimen into the bowl, and proceeds to whip the liquid with the two sticks. This he does for several minutes until a foam is raised. Then, bowing above the bowl, he inhales the older three times. He sets down the bowl, and turns to leave. All this while, he has not uttered a single word. As he nears the door, the woman raises her head and calls out to him in a voice at once urgent and serene. “Thank you, doctor,” she says, and touches with her other hand the place he had held on her wrists, as though to recapture something that had visited their. Yeshi Dhonden turns back for a moment to gaze at her, then steps into the corridor. Rounds are at an end.

      We are seated once more in the conference room. Yeshi Dhonden speaks now for the first time, in soft Tibetan sounds that I’ve never heard before. He has barely begun when the young interpreter begins to translate, the two voices continuing in tandem – a bilingual fugue, the one chasing the other. It is like the chanting of monks. He speaks of winds coursing through the body of the woman, currents that break against barriers, eddying. These vortices are in her blood, he says. The last spendings of an imperfect heart. Between the chambers of her heart, long, long before she was born, a wind had come and blown open a deep gate that must never be opened. Through it charged the full waters of her river, as the mountain stream cascades in the springtime, battering, knocking loose the land, and flooding her breath. Thus he speaks, and is silent.

      “May we now have the diagnosis?” A professor asks.

      The host of these rounds, the man who knows, answers. “Congenital heart disease,” he says. “Interventricular septal defect, with resultant heart failure.”

      A gateway in the heart, I think. That must not be opened. Through it charge the full waters that flood her breath. So! Here then is the doctor listening to the sounds of the body to which the rest of us are deaf. He is more than doctor. He is Priest.

      I know, I know, the doctor to the gods is pure knowledge you’re healing. The doctor to man stumbles, most often wound; his patient must die, as must he.

      Now and then it happens, as I make my own rounds, but I hear the sounds of his voice, like an ancient Buddhist prayer, its meaning long since forgotten, only the music remaining. Then the jubilation possesses me, and I feel myself touched by something divine.”

      [1976: Richard Selzer, MD, Mortal Lessons: Notes on the art of surgery]

      http://bgladd.blogspot.com/2009/05/us-health-care-policy-morass.html

    • rbaer says:

      I think the wikipedia entry may be helpful
      http://en.wikipedia.org/wiki/Evidence-based_medicine

      Yes, some doctors are operating more or less on what they have been taught (even though it may be out of date) or what they experienced (e.g. I tried intervention x for this patient even though it is not indicated – had great success and I will do this again – even though it may have been coincidence or placebo response). The problem of course is that there are many medical interventions that are not proven by EBM standards, but noone will forego these interventions/treatments and no double blind randomized controlled trials (RCT – the gold standard for EBM) will be performed. Also, there are many conditions or situations with such a small N that you will never have a RCT demonstarting their efficacy.

      • So basically, rbaer, you are saying that without some guiding entity sifting through various evidence and formulating their conclusions, individual practitioners are just not going to bother to stay up to date? Or are not able to stay up to date due to sheer volume? Or maybe that it is worrisome that folks may interpret evidence in variable number of ways, and it is better to have a single way of doing things?

        • BobbyG says:

          A central conundrum of medical care is the relatively loose coupling of cause(s) and effect. If you have an adverse patient outcome, does it necessarily follow that you did one or more things “wrong”? Conversely, can you legitimately take causal credit for all of your good outcomes?

          Asked and answered.

          • Well, I know that some folks have this vision of being able to collect a large number of data points from the patient, feed it to the computer, which will sift through mountains of “evidence” and based on some algorithms (programmed by whom?) will display a ranked list of differentials. This is the personalized EBM that Dr. Weed, I believe, is proposing.

            What if you pick, #2 because you think you know better and the patient is harmed? Are you liable for malpractice?
            Alternatively, what if you pick #1 and the patient is harmed? Are you liable precisely because you should have known better?
            And if you pick #5 and the patient is cured, do you get a medal?

        • rbaer says:

          I don’t know … I can only say something about the care of patients who have seen other doctors (of my specialty or, to a limited degree, of other specialties) and docs I interact with. In general, EBM is on the rise (taught in all medical schools) and it may be in part a generational problem. I have seen doctors explaining nonsensical, non EBM stuff they are doing with a certain pride and reference to their expertise and experience. Some academic doctors like elaborate theories based on their knowledge of pathophysiology and biochemistry, but unfortunately, history teaches us that this usually remains entirely speculative and that DBRCT destroy a lot of intuition and speculation.

          “Or maybe that it is worrisome that folks may interpret evidence in variable number of ways, and it is better to have a single way of doing things?”
          Not all medicine is hard facts as you know, and interpretation of subjective phenomena like pain, shortness of breath and dizziness is a challenge, esp. bringing them into context with objective findings (but even objective findings like, say, an abnormal scan are often based on a judgment call). The best answer is probably to reduce subjectivity as much as possible and to follow guidelines whereever possible, but to use good judgment whenever needed (that means, quite often).

  18. BobbyG says:

    Yeah, Margalit. That’s the conundrum. But, I think you’re mischaracterizing the Weeds’ book just a bit. Yeah, the book is radical — almost utopian in some areas — but it has a lot more going for it than a lot of other stuff I’ve read, both in terms of argument and citation.

    In empirical reasoning, you’re always screwed. “n’ too small or unrepresentative? Anecdotal. “n” too large? Well, now you got the “sigma/sqrt(n)” problem of “statistical” vs “clinic significance” (one of my picks with this whole nascent “Big Data” lovefest).

    And, of course, the auditors, regulators, and lawyers ALWAY have perfect 20/20 hindsight.

    “And if you pick #5 and the patient is cured, do you get a medal?”

    Precisely my question.

    Taleb is quite good on these sorts of problems.

  19. EMR Pilot says:

    Margalit touches on one on the central issues with Meaningful Use. It was SOLD as way to help bend the cost curve (i.e. save money from duplicative lab tests, more efficient practice of medicine, etc.). To save billions of dollars more than it costs. Of course, we all know that it’s not gonna!

    But that’s what HIMSS, Allscripts, GE, Epic, etc. convinced bipartisan legislators and the Obama administration was going to happen. Remember when someone published an article citing that docs with EMRs order more tests than those without? The response from Farzad was tremendous. All of a sudden the methodology for studies was REALLY important (and this one was flawed, he told us). Not that ONC or anyone for that matter knows better. By design.

    Progress toward our goal is measured in number of successful attestations to MU. Or was it the number of docs who registered for MU (or signed up with their REC). Either way, Meaningful Use is swimmingly successful (at least that’s what Farzad / WH are telling Congress).

    If anything, widespread implementation of systems with functions that support FFS optimization represent one more hurdle to moving away from FFS and toward truly patient-centered, accountable care.

    After a learning curve (of varying time and depth), practices generally come out the other end able to more rapidly and thoroughly document (at least for billing purposes). It might take awhile but it happens.

    One part that Margalit didn’t cover, though, is that there are scores of products on the market. And all of them aren’t created equal in terms of how quickly they are to learn and ease and productivity of documentation. Some choices are better than others. Now that would be some great research for the market!

    EMR Pilot

    • Great pen name, seeing how people keep comparing health care to aviation.

      Anyway, to your last point, my educated guess would be that the same small handful of inpatient EHRs and the dozen or so of full-featured ambulatory products that have the largest market share, are also the ones excelling at optimizing billings for their clients.

  20. John Ballard says:

    Yesterday’s NY Times had a timely article by Dr. Kleinke, someone familiar to readers at this blog, The Conservative Case for Obamacare. A lot of what he says is germane to this discussion.

    The core drivers of the health care act are market principles formulated by conservative economists, designed to correct structural flaws in our health insurance system — principles originally embraced by Republicans as a market alternative to the Clinton plan in the early 1990s. The president’s program extends the current health care system — mostly employer-based coverage, administered by commercial health insurers, with care delivered by fee-for-service doctors and hospitals — by removing the biggest obstacles to that system’s functioning like a competitive marketplace.

    ==►Read it…
    http://www.nytimes.com/2012/09/30/opinion/sunday/why-obamacare-is-a-conservatives-dream.html?_r=0

    • I wonder, John, at point in the narrative did the problem of the uninsured became one of free-loaders devoid of personal responsibility. With few exceptions, people don’t have health insurance because they are too poor to buy any. Just because the Heritage Foundation declared it to be a personal responsibility issue, doesn’t mean it is so, and the fact that this administration adopted this rhetoric all the way to the Supreme Court, is extremely frustrating.
      Health care is just too expensive (and “shockingly” it seems that computerizing it is not making it any cheaper) and people are getting poorer and in aggregate sicker and older too. Personal responsibility is irrelevant to this subject.

      • John Ballard says:

        You’re right. Personal responsibility is a coded way of framing an argument which is really about individual versus collective responsibility. And the moment anyone speaks the word collective it triggers a visceral negative response beginning with “socialism” and ending with “lazy moochers.” It was bad enough before the election, but the Randian revival brought about by the likes of Paul Ryan and Ron Paul has made it toxic.

        In the last twenty-four hours I have come across three unrelated manifestations of that thinking. The anti-vaccination crowd is a large and growing threat to public health resting on that “individual responsibility” idea, the other side of which is “individual freedom.” Never mind protecting the herd. I’m not gonna be told what to do. I just read a Facebook link to some shaggy dog story about Davy Crockett who wrote some long entry in his diary (after he entered politics) about how someone explained to him that as an elected representative he had no Constitutional right to use public money for “individual charity.” And on NPR last night a panel discussion of the banking sector devolved into a hand-wringing session over the fact that financial institutions which were once dedicated to the well-being of their clients/ customers seem to have lost all sense of fiduciary responsibility and now see the deposits of their customers/ clients as a way to drive corporate profits of those institutions even if it means allowing their customers/ clients to lose assets as a result.

        It just keeps going. Individual selfishness now trumps collective responsibility for more and more people. Nothing short of a foreign military invasion will get their attention. And the reality of millions of our fellow citizens fighting losing battles with ordinary living expenses is lost on those not faced with the same problems. I’ve got mine, so you get yours (and don’t expect me to help — you’re on your own).

        A good place to start getting everybody’s attention, from the corporate and institutional level to the individual level, is to cease or limit tax-favored treatments of insurance premiums. As long as group insurance is a deductible business expense (shared by employees) the horrendous costs are lost in the accounting, along with utility bills, mileage and depreciation of capital expenses. If group insurance could be seen for the revenue hemorrhage that it really is, both companies and employees would start paying attention to what’s on those medical bills that are now being blindly shuffled along with little or no critical oversight. Companies have “loss control managers” of course, but if everybody in the organization were part of his team his job would be to coordinate feedback instead of being the only person in the company with a finger in the dyke.

        Those of us in favor of a single payer system never had a seat at the table from the start of 2009, so that obvious solution was never seriously considered. What we got in return is a national version of the Massachusetts plan across state lines (hello, Conservative critics) with billing left completely in the hands of the private sector. I can hear the complaints about that “IPAB Death Panel” already but the reality is that those are nothing but recommendations and determinations about how our “public money” (which everybody knows is a finite amount) will be divided in a way that will serve the greatest good for the greatest number. And the same voices that complain about “government picking winners and losers” will all want to be picked as winners in this instance with no consideration of the consequences for those who lose.

Leave a Reply

FROM THE VAULT

The Power of Small Why Doctors Shouldn't Be Healers Big Data in Healthcare. Good or Evil? Depends on the Dollars. California's Proposition 46 Narrow Networking
MASTHEAD STUFF

MATTHEW HOLT
Founder & Publisher

JOHN IRVINE
Executive Editor

JONATHAN HALVORSON
Editor

JOE FLOWER
Contributing Editor

MICHAEL MILLENSON
Contributing Editor

ALEX EPSTEIN
Director of Digital Media

MICHELLE NOTEBOOM Business Development

MUNIA MITRA, MD
Clinical Medicine

Vikram Khanna
Editor-At-Large, Wellness

THCB FROM A-Z

FOLLOW US ON TWITTER
@THCBStaff

WHERE IN THE WORLD WE ARE

The Health Care Blog (THCB) is based in San Francisco. We were founded in 2004 by Matthew Holt and John Irvine.

MEDIA REQUESTS

Interview Requests + Bookings. We like to talk. E-mail us.

BLOGGING
Yes. We're looking for bloggers. Send us your posts.

STORY TIPS
Breaking health care story? Drop us an e-mail.

CROSSPOSTS

We frequently accept crossposts from smaller blogs and major U.S. and International publications. You'll need syndication rights. Email a link to your submission.

WHAT WE'RE LOOKING FOR

Op-eds. Crossposts. Columns. Great ideas for improving the health care system. Pitches for healthcare-focused startups and business.Write ups of original research. Reviews of new healthcare products and startups. Data-driven analysis of health care trends. Policy proposals. E-mail us a copy of your piece in the body of your email or as a Google Doc. No phone calls please!

THCB PRESS

Healthcare focused e-books and videos for distribution via THCB and other channels like Amazon and Smashwords. Want to get involved? Send us a note telling us what you have in mind. Proposals should be no more than one page in length.

HEALTH SYSTEM $#@!!!
If you've healthcare professional or consumer and have had a recent experience with the U.S. health care system, either for good or bad, that you want the world to know about, tell us about it. Have a good health care story you think we should know about? Send story ideas and tips to editor@thehealthcareblog.com.

REPRINTS Questions on reprints, permissions and syndication to ad_sales@thehealthcareblog.com.

WHAT WE COVER

HEALTHCARE, GENERAL

Affordable Care Act
Business of Health Care
National health policy
Life on the front lines
Practice management
Hospital managment
Health plans
Prevention
Specialty practice
Oncology
Cardiology
Geriatrics
ENT
Emergency Medicine
Radiology
Nursing
Quality, Costs
Residency
Research
Medical education
Med School
CMS
CDC
HHS
FDA
Public Health
Wellness

HIT TOPICS
Apple
Analytics
athenahealth
Electronic medical records
EPIC
Design
Accountable care organizations
Meaningful use
Interoperability
Online Communities
Open Source
Privacy
Usability
Samsung
Social media
Tips and Tricks
Wearables
Workflow
Exchanges

EVENTS

TedMed
HIMSS South x South West
Health 2.0
WHCC
AHIP
AHIMA
Log in - Powered by WordPress.