By Hayward K. Zwerling, MD

Last summer, the Commonwealth of Massachusetts enacted legislation that will fundamentally alter the physician-patient relationship by giving politicians the right to specify the processes that must occur during an office visit. The relevant law is Section 108 of Chapter 224 of the Acts of 2012, which reads as follows:

The first paragraph of section 2 of chapter 112 of the General Laws … is hereby amended by inserting (the following)… The board (of Registration in Medicine) shall require, as a standard of eligibility for (medical) licensure, that applicants demonstrate proficiency in the use of computerized physician order entry, e- prescribing, electronic health records and other forms of health information technology, as determined by the board. As used in this section, proficiency, at a minimum shall mean that applicants demonstrate the skills to comply with the “meaningful use” requirements (1).

Thus, any Massachusetts physician who does not use a Federally certified EMR AND meet the contemporary Meaningful Use requirements will be denied a license to practice medicine effective 2015. Most unfortunately, the Meaningful Use mandates will continue to become every more onerous in Stages 2, 3, 4, 5, 6 and 7.

As we all know, the practice of medicine has become increasingly difficult as a result of external mandates. These mandates specify which medicines we may prescribe, which radiology tests we can order, how many days our patients are allowed to remain in the hospital, which CME classes we must take, etc. And now, the politicians intend to tell physicians which software they must use in their office and which EMR options must be utilized during the office visit.

The Government’s decision to foist “certified” EMRs on the medical profession is predicated on the hypothesis that the widespread adoption of EMRs will eventually reduce the cost of healthcare. Unfortunately, data published to-date does not support this hypothesis (2). Thus, the continued imposition of the EMR mandates will only delay the implementation of a truly effective solution that could reduce the cost of healthcare.

As the developer of an EMR, I sincerely believe that a well designed EMR is a useful tool for many practices. However, the Federal and State Government’s misguided obsession to stipulate which features must be in the EMRs, and how the physician should use the EMRs in the exam room places the politicians in the middle of the exam room between the patient and the physician, and seriously disrupts the physician-patient relationship.It is past time that physicians reclaim control of their offices, if not the practice of medicine.

Continue reading “The EMR Use Rule: An Open Letter to Massachusetts Physicians”

Berenson, Pronovost & Krumholz

There is growing interest in relying more on outcome measures and less on process measures, since outcome measures better reflect what patients and providers are interested in. Yet establishing valid outcome measures poses substantial challenges—including the need to riskadjust results to account for patients’ baseline health status and risk factors, assure data validity, recognize surveillance bias, and use sufficiently large sample sizes to permit correct inferences about performance. We believe the operational challenges of moving to producing accurate and reliable outcome measures, though daunting, are worth the effort to overcome.

Patients, payers, policy-makers, and providers all care about the end results of care—not the technical approaches that providers may adopt to achieve desired outcomes, and may well vary across different organizations. Public reporting and rewards for outcomes rather than processes of care should cause provider organizations to engage in broader approaches to quality improvement activities, ideally relying on rapid-learning through root cause analysis and teamwork rather than taking on a few conveniently available process measures that are actionable but often explain little of the variation in outcomes that exemplifies U.S. health care.

However, given the inherent limitations of administrative data, which are used primarily for payment purposes, and even clinical information in electronic health records (EHRs), consideration should be given to developing a national, standardized system for outcome reporting [1]. A new outcome reporting system would not be simple or inexpensive, but current data systems may simply be insufficient to support accurate reporting of outcomes. An example is the National Health Care Safety Network system for reporting health care infections [2].

Continue reading “1. Decisively move from measuring processes to outcomes.”

By William Hersh, MD

A recent blog posting calls for a “universal EMR” for the entire healthcare system. The author provides an example and correctly laments how lack of access to the complete data about a patient impedes optimal clinical care. I would add that quality improvement, clinical research, and public health are impeded by this situation as well.

However, I do not agree that a “universal EMR” is the best way to solve this problem. Instead, I would advocate that we need universal access to underlying clinical data, from which many different types of electronic health records (EHRs), personal health records (PHRs), and other applications can emerge.

What we really need for optimal use of health information is not an application but a platform. This notion has been advanced by many, perhaps most eloquently by Drs. Kenneth Mandl and Isaac Kohane of Boston Children’s Hospital [1,2]. Their work is being manifested in the SMART platform that is being funded by an ONC SHARP Award.

Continue reading “Universal EHR? No. Universal Data Access? Yes.”

By Jeff Goldsmith

There has been a lot of controversy in health policy circles recently about hospital market consolidation and its effect on costs.  However, less noticed than the quickened pace of industry consolidation is a more puzzling and largely unremarked-upon development:  hospitals seem to have hit the wall in technological innovation.   One can wonder if the two phenomena are related somehow.

During the last three decades of the twentieth century, health policymakers warned constantly that medical technology was driving up costs inexorably, and that unless we could somehow harness technological change, we’d be forced to ration care.  The most prominent statement of this thesis was Henry Aaron and William Schwartz’s Painful Prescription (1984).  Advocates of technological change argued that higher prices for care were justified by substantial qualitative improvements in hospitals’ output.

Perhaps policymakers should be careful what they wish for.  The care provided in the American hospital of 2013 seems eerily similar to that of the hospital of the year 2000, albeit far more expensive.    This is despite some powerful incentives for manufacturers and inventors to innovate (like an aging boomer generation, advances in materials, and a revolution in genetics), and the widespread persistence of  fee for service insurance payment that rewards hospitals for offering a more complex product.

Technology junkies should feel free to quarrel with these observations.  But the last major new imaging platform in the health system was PET , which was introduced into hospital use in the early 1990’s.  Though fusion technologies like PET/CT and PET/MR were introduced later, the last “got to have it” major imaging product was the 64 slice CT Scanner, which was introduced in 1998.  Both PET and CT angiography were subjects of fierce controversy over CMS decisions to pay for the services.

Continue reading “Hospitals’ Twenty First Century Time Warp”

By Rob Lamberts, MD

There was a hole in the wall of our bathroom that was a painful reminder of a bad encounter with a plumber.  Yes, that hole has been there about a year, and it has been on my to-d0 list for the duration, daring me to show if I inherited any of the fix-it genes I got from my father.  Why not hire someone to come fix it?  I also got (as I mentioned in my last post) dutch genes, which scream at me whenever I reach for my wallet.  So this hole was giving me shame in surround-sound.

I attempted to fix it the hole last year, even going to the degree of asking for  a router table for my birthday.  Since there was previously no way to get to this all-important access to the shower fixture without cutting through the sheetrock, I decided I would take a board, cut it larger than the hole, then use the router to make a rabbet cut so the panel would fit snuggly.  Up until then, I thought a rabbet cut was a surgery to keep the family pet population under control, but my vocabulary was suddenly expanded to include words like rabbet, roundover, chamfer, dado and round nose. Unfortunately, my success only came in the realm of vocabulary, as I was not able to successfully master the rabbet cut without making the wood become a classic example of the early american gouge woodworking style.

I am not sure why, but something inside me told me today was the day to give this another shot, and to my shock (and that of my family), I was successful!

This home project is actually a late comer to the DIY party I’ve been holding for the past few months.

• Don’t like your practice?  Build your own from scratch!
• Don’t like the health care system, build a new one!

My latest DIY venture is in an area I swore I’d not go: I’m building my own record system.

Continue reading “The DIY Electronic Medical Record”

By Missy Krasner

You probably saw some of the headlines last week where Box announced that is supporting HIPAA and HITECH compliance, signing Business Associate Agreements, (BAAs) and integrating with several platform app partners such as  Doximity, drchrono, TigerText, and Medigram to help seed its new healthcare ecosystem.  I also announced that I was formally advising Box on their healthcare strategy.

I was drawn to Box because of all the lessons I learned at Google building a consumer-directed, personal health record (PHR), Google Health. Google Health allowed you to securely store, organize and share all of your medical records online and control where your data went and how it was managed. It was unlike the other PHRs in the industry that were tethered to the provider or payor or part of an Electronic Health Record (EHR) system.

Sound good? Well, it was in theory. The big issue with Google Health was aggregating your data from the disparate sources that stored data on you.  We had to create a ton of point-to-point integrations with large health insurance companies, academic medical centers, hospitals, medical practices and retail pharmacy chains. All of these providers and payors were covered entities in the world of HIPAA and were required to verify a patient’s identity before releasing any data to them electronically. It was a very bumpy user experience for even the most super-charged, IT savvy consumer.

Continue reading “Box Picking Up Where Google Health Left Off”

By Rob Lamberts, MD

It’s been a long time since I wrote a post.  My life, you see, is incredibly dull and boring.  There has been so little to write about that I’ve been at a loss.

No, actually that’s a load of crap.  It’s become a fantasy of mine to have such boredom.  In reality, my life is as un-boring as it could be.  It’s like the part of a story where everything is in flux, where little decisions have huge consequences, and where the inflection point between a comedy and tragedy is located.

So how’s my new practice going?  In some ways things are going about as well as they could.  My patients are amazed when I answer their emails or (even more surprisingly) answer the phone.  ”Hello, this is Dr. Lamberts,” I say.  This usually results in a long pause, followed by a confused and timid voice saying something like, “well…uh…I was expecting to get Jamie.”  Yet I am often able to deal with their problems quickly and efficiently, forgoing the usual message from Jamie to get to the root of their problem.  It’s amazingly efficient to answer the phone.

Financially, the practice has been in the black since the first month, and continues to grow, albeit slowly.  The reason for the slow growth is not, as many would predict, the lack of a market for a practice like mine.  It’s also not that I am so busy at 250 patients that growth is difficult.  In truth, when we aren’t rapidly adding new patients, the work load is nowhere near overwhelming for just me and my nurse.  In that sense I’ve proved concept: that it’s not unreasonable to think I can handle 500, and even 1000 patients with the proper support staff and system in place.

Which brings us to the area of conflict, the crisis point of this story: the system I have in place.  The hard part for me has been that I have not been able to find tools to help me organize my business so it can run efficiently.

Continue reading “The Electronic Medical Record and the Patient Narrative”

By Shirie Leng, MD

Dear Tech Guys:

So today I’m doing anesthesia for colonoscopies and upper GI scopes. Nowadays we have three board-certified anesthesiologists doing anesthesia for GI procedures every single day at my institution. I’ll probably do 8 cases today. I will sign into a computer or electronically sign something 32 times. I have to type my user name and password into 3 different systems 24 times. I’m doing essentially the same thing with each case, but each case has to have the same information entered separately. I have to do these things, but my department also pays four full-time masters-level trained nurses to enter patient information and medical histories into the computer system, sometimes transcribed from a different computer system. Ironically, I will also generate about 50 pages of paper, since the computer record has to be printed out. Twice.

No wonder almost everyone I know hates electronic medical records! I don’t know anything about computers, and I don’t know what systems other hospitals have. I may be dreaming of a world that doesn’t exist or that world is here and I haven’t heard about it. Nevertheless, here’s my wish list for a system that doctors would actually want to use:

1. Eliminate the User Names and Passords: You can’t tell me that in this day of retinal scans and hand-held computers that there isn’t a better way to secure data. What if each person had their own iPad that you only have to sign into ONCE a day that automatically signs your charts. If you’re worried about people leaving them sitting around use a retinal scan or fingerprint instant recognition system.

2. Eliminate the Paper: If you’re going to have full-time people entering data for you, why print it out? It’s on the computer for anyone to access.

3. All Data Systems Must Be Compatible: You can’t have patient data entered in one place that doesn’t automatically import into another place. If my anesthesia record can’t talk to the hospital OMR, I have to RE-TYPE everything in, which is completely ridiculous.

4. Everybody Has to Use the Same System: Everybody, state-wide. Right now, electronic records from a nearby hospital are not available at my hospital, even though the two hospitals are right across the street from each other.

5. Don’t Make Me Turn the Page All the important information about a patient should be on the first page you open when you look up a patient. I shouldn’t have to click six different tabs. Specific to anesthesia, all the relevant data about the patient including what medications they have received during the case should be automatically displayed on the screen when you start a case. Specific to primary care, all the latest labs and data, recent appointments with specialists, current med list and anything else the doctor wants to see commonly should be right on the first screen.

Continue reading “The Email I Want to Send To Our Tech Guys But Keep Deleting…”

By Shirie Leng, MD

I am affiliated with the institution where Dzhokhar Tsarnaev is currently hospitalized.  I am friends with people who have treated him.  I’m trying to stay away from those people; I would be unable to help asking them about him.  They might be unable to help talking about him.    There has been a flurry of emails and red-letter warnings cautioning people here not to talk about Mr. Tsarnaev or look him up on the EMR (Electronic Medical Record) system.  Despite this there have been leaks of information and photos from various sources.  It is virtually impossible to keep people from asking about him and talking about him.  Curiosity is human nature.  When human nature comes up against morals and laws, human nature will win a good percentage of the time.  The question is:  given what he has done, does this 19-year-old still have his right to privacy?

The answer, of course, is yes.  The American Medical Association includes patient confidentiality in it’s ethical guidelines:

“…the purpose of a physicians ethical duty to maintain patient confidentiality is to allow the patient to feel free to make a full and frank disclosure of information…with the knowledge that the physician will protect the confidential nature of the information disclosed.”

Threre are legal guidelines as well, most notably with the Health Insurance Portability and Accountability Act, or HIPAA.  This law was originally passed in 1996 to improve the efficiency and effectiveness of the health care system, allow people to switch jobs without losing their health insurance, and impose some rules on electronic medical information. Congress incorporated into HIPAA provisions that mandate the adoption of  the Federal privacy protections for health information.  The “simplified” administrative document for the privacy and security portions of HIPAA is 80 pages long.  Basically your health information cannot be shared with ANYONE. Of course, there are exceptions to HIPAA. Continue reading ““Did You Take Care of Tsarnaev?””

By John Moore

Arguably, the biggest news story coming out of HIMSS last month was the announcement of the CommonWell Health Alliance – a vendor-led initiative to enable query-based, clinical data sharing. So much has been written about CommonWell that there is little need to rehash what has been said before.

What has not been said, or at least has been sensationalized nearly to the point of irrelevance is the whole controversy surrounding Epic and how they were not invited to join the CommonWell Alliance until after the announcement. None other than Epic’s own founder and CEO, Judy Faulkner, has gone on record stating the Epic was unaware of CommonWell prior to the announcement. Faulkner has gone on to question the motives of CommonWell, in an effort to subvert it, in her highly influential role on the Dept of Health & Human Services HIT workgroup committee.

That was the last straw.

It is one thing to moan and groan at the HIT love fest that is HIMSS, where vendors commonly discount the announcements of competitors. But it is quite another thing to be a part of a highly influential body that is defining nationwide HIT policy and make the same claims over again, especially when they are frankly not true.

Continue reading “The Story Behind the CommonWell Story”