We continue to see progress in improving the nation’s health care system, and a key tool to helping achieve that goal is the increased use of electronic health records by the nation’s doctors, hospitals, and other health care providers. These electronic tools serve as the infrastructure to implementing reforms that improve care – many of which are part of the Affordable Care Act.
Doctors and hospitals are using these tools to reduce mistakes and hospital readmissions, provide patients with more information that enable them to stay healthy, and allow for rewarding health care providers for delivering quality, not quantity, of care.
The adoption of those tools is reflected today in a release from the Centers for Disease Control and Prevention’s National Center for Health Statistics which provides a view of the Medicare and Medicaid EHR Incentive Program and indicates the program is healthy and growing steadily.
The 2013 data from the annual National Ambulatory Medical Care Survey are encouraging:
- Nearly 80% of office-based physicians used some type of electronic health record system, an increase of 60 percentage points since 2001 and nearly double the percent in 2008 (42%), the year before the Health Information Technology and Economic and Clinical Health Act passed as part of the Recovery Act in 2009.
- About half of office-based physicians surveyed said they use a system that qualifies as a “basic system,” up from just 11% in 2006.
- Almost 70% of office-based physicians noted their intent to participate in the EHR incentive program.
Figure 1. Percentage of office-based physicians with EHR systems: United States, 2001-2013
The report also noted that 13% of physicians who responded said they both intended to participate in the incentive program and had a system that could support 14 of the Meaningful Use Stage 2 “core set of objectives,” ahead of target dates. This survey was performed in early 2013 – before 2014 certified products were even available.
Continue reading “Survey Says: EHR Incentive Program Is on Track”
Filed Under: Tech, THCB, The Business of Health Care
Tagged: EHR, EHR Incentive Programs, HIT, Karen DeSalvo, Meaningful Use, National Center for Health Statistics, ONC, Physicians
Jan 17, 2014
In a previous blog we demonstrated how guidelines can compromise the care of individual patients when designed to serve the health care system.
Why should treating physicians defer to guideline committees at all, we asked? For decades medical students have been taught to read and understand information from published papers.
We are all trained in critical appraisal and can keep up with the clinically meaningful literature, the literature that is relevant and accurate enough to present to patients. Just because there are nearly 20,000 biomedical journals does not mean that any, let alone all are replete with meaningful information. We can discern the valuable from the not valuable; why do we need others to tell us?
In fact, we even argued in our last post that patients can and should judge the value of medical information. After all, they face the consequences of misinterpreting the likelihoods of benefit and of harm associated with various options for care.
No one remembers the numbers that describe the chances for benefit and harm or ask more questions about the veracity of information than a patient who must choose. The smartest information managers we have ever encountered are our patients; when informed, they quickly determine the validity of the information and apply their personal values to the estimations of the chances for benefit and harm.
Take the example of a patient who recently entered into a therapeutic dialogue with one of us, RAM. This was not the traditional clinical interview. This patient had been diagnosed with prostate cancer and was scheduled for an approach to treatment that the diagnosing physician had offered as the most sensible. However, the decision did not rest easily.
The appointment with RAM was scheduled because the patient sought a dialogue that might offer a chance to reflect on the rationale for the approach he was about to initiate. Two hours into the dialogue, the patient, a 40ish year old African-American man accompanied by his wife, were mulling over the marginal benefits and harms of the options for treating an early stage prostate cancer.
The wife asked how many African-Americans were in the study under discussion. “None”. The husband perked up and then asked, “How many people in the study was my age?” “None”. They then asked if the difference in benefit was a certain, fixed amount? “No, it varies over this range.” – examining the descriptive statistics.
They then asked when the study was started and did it pertain to the present day. “It started over 15 years ago” and the stage of disease of the men in the study was generally more aggressive than in this particular case.
Continue reading “Fee for Service vs. Fee for Serving”
Filed Under: OP-ED, THCB
Tagged: Costs, doctor/ patient relationship, Fee-for-service, Nortin Hadler, Physicians, practice of medicine, Robert McNutt
Jan 15, 2014
Besides the importance of physician happiness when using an EHR, using design principles that maximize user intuition and presentation of relevant information, there is one aspect of health care information systems that should never be overlooked…patient safety.
Scot Silverstein, MD, blogging at Health Care Renewal as InformaticsMD, frequently brings to light issues surrounding health care IT implementations that compromise patient safety. Reading his posts should be sobering and concerning to both medical professionals and the public alike. Like I’ve said, health care IT, in my opinion, is still in its infancy despite the number of years computers have been around and the existence of Meaningful Use legislation.
As a practicing physician as well as a software coder, I’ve used a number of EHR’s (and still currently using a well known EHR by my employer of my part time job) to know how some of these appalling user interfaces affect not just workflow and user happiness, but patient safety.
An example of one design element that most physicians may not be able to identify, ironically, is the one that is most harmful when it comes to patient safety. In this well known EHR, you are presented a medication list for a patient. As a physician, you assume that this list is a current medication list and is up to date. However, the reality is that this EHR system automatically removes a medication from the list when it is determined to be expired even if it should be appearing on the current medication list.
When a physician prescribes a medication from this system, it calculates the duration of usage of the medication based on the instructions, quantity of medication prescribed, and the number of refills. Once the duration exceeds the number of days that has elapsed since the prescription was made, the medication is taken off the current list automatically by the EHR. Now, taken at face value, this sounds like the logical approach to manage a medication list and utilizes the computing power that an EHR will gladly show off as a benefit to physicians.
Unfortunately, the EHR programmers failed to understand that medications are not taken regularly by all patients all the time. In fact, no physician assumes that at all. So why should an EHR make that assumption? Furthermore, there are plenty of treatments that are to be taken only as needed so how can an EHR account for that? Absolutely, impossible.
Continue reading “Why EHR Design Matters”
Filed Under: Tech, THCB
Tagged: Design, EHR, Michael Chen, Patient Safety, Physicians
Dec 18, 2013
The Massachusetts Medical Society may be the first to notice that Meaningful Use EHR mandates favor large providers and technology vendors. Control over the Nationwide Health Information Network sets the stage for how physicians refer, receive decision support, report quality, and interact with patients. State health information exchanges and policy makers are caught in the cross-fire over health records interoperability. Are the federal regulations over Stage 2 being manipulated to put physicians and the public at a disadvantage?
On Dec. 7, the Massachusetts Medical Society took what might be the first formal action in the nation. A resolution stating:
“That the Massachusetts Medical Society advocate for a more open, affordable process to meet technology mandates imposed by regulations and mandates; e.g., that all Direct secure email systems, mandated by Meaningful Use stage 2, including health information exchanges and electronic health record systems, allow a licensed physician to designate any specified Direct recipient or sender without interference from any institution, electronic health record vendor, or intermediary transport agent.”
Scott Mace’s column Direct Protocol May Favor Large Providers and Vendors is the first to report on this unusual move by a professional society. Full disclosure: I’m a member of the MMS and the initiator of what became this resolution.
Meaningful Use is intended to support health reform by promoting interoperability and innovation in health service delivery. The Affordable Care Act, Obamacare, is fundamentally a free-enterprise model without single payer or even a public option. Obamacare depends on the market for eventual cost controls and sustainability. Meaningful Use is regulation designed to enable market-driven health reform by reducing interoperability barriers.
Although Meaningful Use regulations have already handed out $17 Billion to drive “voluntary” adoption of interoperable electronic health records, meaningful interoperability is still elusive. Meanwhile, the doctors are chafing about Meaningful Use intrusions and policymakers worry that the regulations will actually increase costs.
Continue reading “It’s Doctors versus Hospitals Over Meaningful Use”
Filed Under: Tech, THCB
Tagged: Adrian Gropper, EHR, EHR vendors, Hospitals, Massachusetts Medical Society, Meaningful Use Stage 2, Physicians
Dec 12, 2013
Thank you, my patients for all you have done for me. Thank you for the encouragement and support. Thank you for believing in me enough to join me in this crazy new way to do health care. Thank you for giving me the honor of being the one you call “my doctor.”
Your trust motivates me to work harder to justify that faith in me – a faith I often don’t have and, one I certainly wouldn’t have without you. I hope and pray this holiday season is a blessing to you. May you find peace in this time of year so often without peace.
May you also have a happy and healthy new year. May you stay out of the ER, away from the hospital and, yes, away from doctors. May you have no need for lab tests, procedures, x-rays and medications (and if you must have medications may they be very cheap.)
If, however, you do get sick, remember that I am here to help you get well, feel better or avoid getting any worse. And if I cannot do any of these, I will still be there to stand by your side through the hard times, and to offer whatever comfort I can give. Doing these things is what it means to me when you call me “my doctor.” It is why that is such an honor.
Again, thank you for all you do for me. God bless you.
Rob Lamberts, MD, is a primary care physician practicing somewhere in the southeastern United States. He blogs regularly at More Musings (of a Distractible Kind),where an earlier version of this post first appeared.
Filed Under: Physicians, THCB
Tagged: Patients, Physicians, practice of medicine, primary care, Rob Lamberts
Dec 8, 2013
I want to update you on ComChart EMR’s “Meaningful Use Certification” status.
ComChart EMR will continued to be certified as a Complete EMR for Stage I Meaningful Use. Unfortunately, we will not be able to meet the Stage 2 (or greater) Meaningful Use certification requirements as these requirements are technically extremely difficult to implement.
In addition to the Meaningful Use mandates, there continues to be a never ending stream of new mandates such as ICD-10, PQRI, Meaningful Use 2, Meaningful Use 3, SNOMED, ePrescribing, LOINC, Direct Project, health information exchanges etc. As a result of the mountain of mandates, ComChart EMR and the other small EMR companies will have to choose to implement the mandates or use their resources to add “innovative” features to their EMR. Unfortunately, the small EMR companies do not have the resources to do both.
(I suspect this is also true, to some extent, for all EMR companies.)
While the individual people involved in promulgating these EMR mandates (mostly) have the best of intentions, they clearly do not understand what transpires in the exam room, as many of the mandated features confer little or no benefit to either the patient or the healthcare provider.
In addition to a lack of understanding of what is important during the process of providing healthcare, it has also become apparent to me that the Federal and State health information technology agenda is now largely driven by the strongest HIT companies and health institutions; the individual physician is only an afterthought in the entire process.
Continue reading “Open Letter From a Small EMR Vendor To Our Customers and Our Friends In Washington”
Filed Under: Tech, THCB
Tagged: EHR, Hayward Zwerling, Meaningful Use Stage 2, Physicians
Dec 5, 2013
So I was at TechfestNW earlier this fall and I had the opportunity to hear James Keller at WalmartLabs speak about the importance of having a minimum valuable (versus viable) product that is tied into the user experience. It is how the user’s emotional response to the application’s interface, which is so important to have, that gives a product meaning.
And this concept (although I admit I completely stumbled upon it) is at the very heart of what makes NOSH ChartingSystem so different. As I have stated on my blogs before and on my Indiegogo campaign site, I wanted to have an EHR that was both intuitive to use AS WELL AS having an interface that was calming and meaningful at the same time. So as an example from the medical world, having a pain scale is pretty good indicator of how user-friendly your application is.
An analogous concept is the OMG-to-WTF scale (see above).
Where does your EMR stand on the scale?
Continue reading “The OMG to WTF? EMR Pain Scale”
Filed Under: Tech
Tagged: Design, EHR, HIT, Michael Chen, Patients, Physicians
Nov 19, 2013
The dull whir of the computer running in the background seemed to have gotten louder as the patient fell quiet. She was a young woman, a primary-care patient of mine, seeking a referral to yet another gastroenterologist. Her abdominal pain had already been checked out by two of the city’s most renowned gastroenterologists with invasive testing, CAT scans and endoscopic procedures.
But she wasn’t satisfied with her diagnosis — irritable bowel syndrome — or the recommended treatment and wanted a third opinion. I tried to reason with her but failed to convince her otherwise. Even when I acquiesced and gave her the referral, she walked out visibly unhappy. I sat there listening to the whirring, feeling disappointed.
Physicians love being liked. They also love doing their jobs well. With other incentives, such as monetary returns, dwindling, the elation we get from satisfying a patient as well as providing them good care is what still makes being a doctor special. But is keeping patients satisfied and delivering high-quality care the same thing? And more important, can patients tell if they are getting good care?
Policymakers certainly think so. In fact, under the Affordable Care Act, Medicare, and Medicaid hospital reimbursements are now being tied to patient satisfaction numbers.
But the association between patient satisfaction and the quality of care is far from straightforward, and its validity as a measure of quality is unclear.
In fact, a study published in April and conducted by surgeons at the Johns Hopkins School of Medicine showed that patient satisfaction was not related to the quality of surgical care. And a 2006 study found that patients’ perception of their care had no relationship to the actual technical quality of care they received. Furthermore, a 2012 UC Davis study found that patients with higher satisfaction scores are likely to have more physician visits, longer hospital stays and higher mortality. All this data may indicate that patients are equating more care with better care.
Although patients and their physicians generally have similar goals, that is not always the case. As a resident, who is not paid on a per-service basis, I have no incentive to order extra testing or additional procedures for my patients if they’re not warranted. But one study found that physicians who are paid on a fee-for-service basis and therefore have an incentive to deliver services — needed or not — are more likely to deliver these services (such as an MRI for routine back pain).
On top of that, as another study found, they also are more liked by their patients. It is no wonder then that the number of patients with back pain, one of the most common reasons for physician visits, are increasingly being overmanaged with MRIs and narcotic pain medications.
Continue reading “In Medicine, More May Not Be Better”
Filed Under: Physicians
Tagged: Haider Javed Warraich, Outcomes, Overtreatment, Patients, Physicians, practice of medicine, Quality
Oct 23, 2013
The shortcomings of the Fee For Service (FFS) model are widely known.
During the 1800s, the British empire shipped prisoners to newly formed penal colonies in Australia (technically, these were British prisoners, but that doesn’t make a catchy title). Ship captains were compensated for each prisoner who boarded the ship. The financial incentive ruled over decency, each captain stuffed as many prisoners on to the ship as it could handle. Of course, the prisoner survival rate lingered at a precarious 50%, while those who managed to survive the journey often arrived beaten, sick or starving.
Attempts were made to improve the survival rates, through what might be considered early wellness programs. Captains were mandated to bring citrus to combat scurvy, a 19th century wellness program. Doctors were required on each ship carrying prisoners, improved access ala concierge medicine. I’m sure someone may have proposed it’s the prisoners responsibility to survive the trip and they ought to engage in their own survival. Nevertheless, requiring lemons and limes and placing physicians on the ships proved equally ineffective.
In 1862, economist Edwin Chadwick suggested a change to the incentive structure. Ship captains were no longer compensated for each prisoner who boarded in England, but, instead, received payment for every living prisoner who got off the ship in Australia. The first pay for outcomes program in healthcare. The survival rate on ensuing trips jumped from 50% to 98%.
The moral of the story is that incentives matter.
- Primary care physicians are the ship captains of the 21st century.
- American patients are prisoners of the US healthcare system.
- Misaligned incentives are the root cause for what ails the system.
Christopher DeNoia is the Vice President of Business Development at Amplify Health, where this post originally appeared.
Filed Under: Physicians, THCB
Tagged: Chris Denoia, Fee-for-service, Incentives, Physicians, Value
Oct 10, 2013
What do Louis Pasteur, Jonas Salk, Sigmund Freud and Barack Obama have in common? They all championed controversial medical revolutions and if not for their bravery in the face of conflict, billions would have died.
Sterilize instruments to kill invisible bugs? Inject disease particles to build immunity? Look into our subconscious to explain everyday behavior? Give basic healthcare to everyone? Ludicrous. That is why we named these advances after these men.
As an oncologist who has seen the fatal cost of our patchy, imbalanced and unfair healthcare system, I have to be at very least hopeful about ObamaCare; AKA the Affordable Care Act (ACA). The list of benefits is so vast that whatever glitches happen along the way, I know that cancer patients will be helped:
-No pre-existing condition exclusion: So the 31-year-old programmer with Stage 1 breast cancer can change jobs without losing insurance.
-Healthcare coverage by parents until their child is 26: So families will not lose their homes paying for Hodgkin’ s disease in a 22-year-old.
-Guaranteed payment by insurers for patients entering experimental trials: So patients with any insurance can be involved in research, and everyone benefits from the latest advances.
-Free healthcare screening: So that my 58-year-old neighbor with a family history of colon cancer gets routine exams and life saving colonoscopies.
-Uniform healthcare insurance standards: So that the 45-year-old man with stomach lymphoma I saw last week, does not have to suffer and die because his employer brought a health policy, which excluded chemotherapy.
Continue reading “The Next Great Cure? A Cancer Doctor Explains Why He Supports the Affordable Care Act”
Filed Under: OP-ED, THCB
Tagged: Cancer, James Salwitz, Oncology, Patients, Physicians, The ACA
Oct 4, 2013