Physicians

An Open Letter to the Obama Health Team

It seems likely that the Obama administration and Congress will spend a significant amount on health IT by attaching it as a first-order priority to the fiscal stimulus package. We take the President-elect at his word when he recently said:

“…we must also ensure that our hospitals are connected to each other through the Internet. That is why the economic recovery plan I’m proposing will help modernize our health care system – and that won’t just save jobs, it will save lives. We will make sure that every doctor’s office and hospital in this country is using cutting edge technology and electronic medical records so that we can cut red tape, prevent medical mistakes, and help save billions of dollars each year.” (December, 6, 2008)

Whether the health IT money is well spent will depend on how it is distributed and what it buys. Most observers suppose that federal health IT investment dollars will be used to help doctors’ offices and hospitals acquire and implement electronic health record systems (EHRs or EMRs). These are commercial software suites for entering, storing and managing patient health data within a practice or health organization.

We agree that some of the federal health IT money should go to purchase EHRs, especially to doctors and hospitals in rural and under-served areas, which otherwise could not afford them.The Easy, Wrong SolutionThe easy solution would be to spend most of the health IT funds on EHRs. The EHR industry has made it easy by establishing a mechanism to "certify" EHR products if they incorporate certain features and functions.

But the easy solution would not be the right one. EHRs still are notoriously expensive. Often, practicing physicians do not consider many of the features and functions to be useful or important.  It can cost as much as $40,000 per physician in a medium size medical practice at the beginning of an EHR implementation. Even that regal sum may not completely cover the hardware and technical support necessary.

EHRs can be difficult to implement, upsetting practice workflows. In general, physicians’ practices have not adjusted quickly or smoothly to the disruptive nature of the switch from paper to electronic systems for patient care. Implementations can take months or even years to stabilize.

And the turmoil associated with the implementation can often have negative revenue repercussions for the medical practices they are intended to help. Physicians routinely report that, during the adjustment period, the number of patients they can see and treat in a day drops by twenty to thirty percent, with a commensurate decline in revenues.

Nor is there conclusive evidence that the use of EHRs improves patient care quality.

Finally, EHRs from different vendors are not yet interoperable, meaning that patient information cannot yet be easily exchanged between systems. If America’s physician practices suddenly rushed to install the systems of their choice, it would only dramatically intensify the Babel that already exists.

These barriers to adoption are well documented; they form the wall that has kept physician EHR adoption overall to less than 25 percent in this country. Even if a hefty federal subsidy reduced the exorbitant cost of the EHRs, many practices would suffer severe negative business impacts, and primary care access could temporarily be reduced on a national scale.

So important as EHRs are, at this point there are far better ways to invest in health IT for the doctor’s office and hospital. These approaches are low cost and would have immediate high impact on the quality and safety of care. They could build on and utilize existing health IT infrastructure, and be relatively non-disruptive to practice workflows. These factors would encourage adoption by minimizing risk for the doctors, their staffs, and their patients.E-prescribing As A ModelThe success of e-prescribing – as health technology and as public policy – makes it a model for future efforts. E-prescribing uses computing devices to enter, modify, review, and communicate prescription information. The entire process can be automated, from a prescribing doctor’s fingertips on the keyboard to the receiving pharmacist’s view of the medication order on his/her monitor. All this is possible through the use of standards- and web-based software that is free or inexpensive to the medical practice.

The only technology required of the doctor is Internet connectivity and access to one of the popular browser software programs, like Internet Explorer or Mozilla Firefox, which are already present in most offices and clinics around the country. E-prescribing takes advantage of this existing infrastructure, which is why its adoption is growing rapidly, particularly after CMS authorized an incentive payment to e-prescribing physicians of 2 percent of their total Medicare allowed charges during 2009.

E-prescribing has succeeded because it is an incremental and low-risk health IT that made it easy for physicians and pharmacists to electronically share prescription data, and because it was encouraged by financial incentives. E-prescribing produced significant benefits to physicians over the short term, but simultaneously provided a pathway to more comprehensive IT use over time. It also avoided a sharp decline in access to primary care.

More Bang, With Less Turmoil, for the BuckWe believe that the Obama administration could leverage IT spending in similarly inexpensive ways. Smaller, incremental steps would likely impact a larger number of medical practices in the short-term, benefiting patients while limiting the disruption to doctors.

Here are three suggestions:

1) Referral Management. No patient ought to be referred from a primary care provider to a specialist unless the relevant personal health data are available. Yet, as often as half the time the paperwork arrives, if it arrives at all, after the patient’s specialist appointment. This wastes time, results in duplication of tests, medications and procedures, and may imperil personal health.

Care can only be coordinated and continuity assured if information follows the patient wherever the next care event will occur. The solution is relatively easy and no more difficult than e-prescribing.

Create financial incentives for the implementation of simple tools that allow doctors and practices to share health data and communicate with other doctors. It should start with the specialists to whom they refer patients, and include the specialist when (s)he returns the patient to the primary care physician. A 1-2 percent bonus to doctors who e-refer would significantly increase continuity of information among doctors, which would translate to better continuity of care for patients, and lower costs to the system.

2) Patient Communications. Patients want and deserve to communicate through secure email with their medical home practices. They also increasingly want to use the Web to schedule appointments, pay bills and view portions of their medical records, such as lab results. These online services are not expensive for medical practices to provide through companies that offer them as “web portals” and they offer more than convenience to patients.

These communication tools are a means of closing the “collaboration gap” that exists between busy physicians and their busy patients, allowing routine tasks to be moved outside the rushed seven-and-a-half-minute office visit. This gives consumers time to digest and reflect upon how best to meet their health and wellness goals and offers doctors the luxury of better-informed patients. While some consumers are willing to pay their doctors an additional monthly fee to obtain these online services, a small payment from Medicare similar to that offered for e-prescribing would make the business case for doctors’ adoption of these patient-friendly online services. Adoption would surge.

3) Infrastructure Build-Up and Maintenance. Nowhere is access to the Internet more essential than in health care. We must assure that broadband Internet connectivity reaches every medical practice and every home in America, no matter how rural a region or how low income a neighborhood. Currently there are too many areas in the country where cable and DSL do not reach, often due to the small numbers of subscribers and the consequent barrier to investment by network carriers this imposes. The federal health IT initiative should subsidize both the establishment of broadband service in those areas, and the subscription fees for low income and health disparity populations that could benefit the most from Internet connectivity with health care providers and online care services.

The new Administration and Congress are about to throw a lot of money at the health IT problem, and the conventional thinking is to buy everyone an EHR of his/her choosing. While we enthusiastically applaud the vision that this represents, a more measured approach would create a smoother and more productive transition. At the same time, it would signal the EHR industry that, for national deployment, they need to come to terms with issues they have avoided so far, like interoperability and cost.

David C. Kibbe MD MBA is a Family Physician and Senior Advisor to the American Academy of Family Physicians who consults on healthcare professional and consumer technologies. Brian Klepper PhD is a health care market analyst and a Founding Principal of Health 2.0 Advisors, Inc.

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48 replies »

  1. This open letter makes two.
    Also see my Dec. 7 “Open Letter to President Barack Obama on Healthcare Information Technology” at Healthcare Renewal ( http://hcrenewal.blogspot.com/2008/12/open-letter-to-president-barack-obama.html ).
    Along with the Joint Commission Sentinel Event Report on HIT ( http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_42.htm ) and the National Research Council report “Current Approaches to U.S. Health Care Information Technology are Insufficient” ( http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=12572 ), I believe the medical informatics community has offered int due diligence towards this initiative.
    Let’s hope we use this wisdom to avoid a repeat of what’s going on in the UK (see http://hcrenewal.blogspot.com/2008/11/should-us-call-moratorium-on-ambitious.html ).

  2. As a healthcare consultant, I am increasingly concerned at the way that information can get buried in the current EMR systems. In order to get CCHIT certification, the vendor has to satisfy requirements and scenarios. However there is no workflow or usability standard. Also, if there is a problem in field matching, important data may not even reach the system. Current EMR systems are pricey and turn physicians into data entry clerks. Physician need to concentrate on patient care and not which click to make and which key to use. The US needs to go electronic but with the systems out there right now I believe medical errors could go up if the users cannot easily and quickly find the data they need.

  3. This will make everyone feel like something is being done. It will not help me with my $7500 deductible or medical bankruptcy. It will help the whole corporate substitution of anything deserving to be called “care.” This is not a solution, it is a distraction, a new profit center complete with its own new czar.

  4. The open letter to the President Obama should include ” the wheel has already been invented”. Its called the VA Health System containing an electronic health record product that crosses state lines and manages the health of 25 million Americans. No commercial product comes close. This is another fine product that we the taxpayers have developed with the help of people from MIT and thousands of talented professionals. The product is here, its scalable, secure and efficient.

  5. Dear Readers:
    I am not a medical professional nor an IT professional. As a person who has been on health insurance for 18 years out of 23 years in US, I find the healthcare system needs to be completely overhauled to provide more education on PREVENTION TO YOUNGER GENERATION.
    How many methods of delivery of services and information are employed, will not reduce the demand on the available systems which is what keeping the cost so high.
    As the world progresses with IT it will be used eventually by all or non users will die being not-competitive enough.
    How do we provide PREVENTION is probably the key and it is a challenge to all of you to come up with a competitive solution.
    The sick at the age 77 may use the system if that person can afford it but if can not why taxes have to pay for it?
    How much can be spent just for our emotions.
    Medicare collects 2.9% of entire GDP as a tax and should be able to provide cost of educating the younger generation to stay out of trouble.
    Sincerely
    Kanayo

  6. David,
    I am appalled by your comments. Coastal Medical Inc has been paperless on eClincialWorks for the last 2 1/2 years, with a fully functional integrated pms/emr. Our initial investment was $1.8 million and our ROI calculation for the 90 providers in 16 locations is 2.9 years. We have admittedly worked hard to achieve this. However, our cost savings in fewer employees, recaptured transcription costs, improved documentation for coding, 100% charge capture, 100% chart and information availability at the patient visit, and med mal discounts have more than compensated. The VPN makes work from home, especially when on call, a dream. The ability to fax key documents and patient information to other providers, hospitals, and agencies streamlines data communication and improves continuity of care. Why advocate for anything less? Mark Jacobs MD, President and CEO, Coastal Medical Inc.

  7. David Kibbe wrote: “We criticize Microsoft for being monopolistic, but we are also danged thankful that they created a standard operating system, because it led to hugely less expensive personal computers.”
    IBM creating a commodity-based open architecture PC hardware, Intel, and AMD had far more to do with making less expensive computers than Microsoft. — IV

  8. It will be companies like WifiMed (WIFM.ob) and Allscripts that will benefit from this administrations spending. They are poised to be clear winners when the administration puts money into healthcare.

  9. Hi David,
    I share your opinion that the incoming Obama administration will spend enormous sums on healthcare IT. There is enormous momentum to do so and I suspect that right or wrong most of the $$$ will go to subsidizing physician adoptions of EHR/EMR systems. In addition, the states — desperate to reduce Medicaid costs — are doing the same and many have already started. Thus, I’m not optimistic that you will succeed in redirecting these “investments” unless you can tap directly into Obama’s inner circle.
    In the meantime, we will proceed to develop our MedKaz™ System which will co-exist with whatever improvements are introduced. I suspect you and I both can use all the help we can get!
    Regards, Merle.

  10. Merle: I applaud your spirit and sincerely hope that you are successful. It seems inevitable to me that the new administration will invest in health IT, and I’d like very much to see that good money isn’t spent after bad. DCK

  11. Dear David,
    Thanks for your response. I understand that your suggested alternatives are presented as just that: alternatives beyond the scope of EHRs/EMRs that will improve care quality and reduce care costs, and that these types of options should be considered for government funding.
    The point I am raising, however, is that if we take the blinders off, it becomes clear we don’t need government funding to solve our patient record/information problems. Therefore, we should charge ahead, not delay.
    With today’s technology and know-how, we can create a system that aggregates a patient’s lifetime health record in a single repository that, in turn, is available when and where a care provider needs it. At the same time, we can satisfy the desire of consumers to control their records. We can do all this without government subsidies and a lot faster and cheaper than “conventional wisdom” proponents think.
    One of the distinctive aspects of our MedKaz™ System is its self-sustaining business model. We pay care providers to upload practice notes, test results, images, etc. to the patient’s MedKaz™ so it always is up to date. (When was the last time you saw someone actually offer to pay physicians and hospitals to help them improve the care of their patients? This may be a first — at least in recent years!) At the same time, we create considerable value for our shareholders and do not require government subsidies!
    One last point. We need not wait until 2012 to put patients’ Lifetime Health Records™ in their hands. We can do it in 2009 — which is what we are striving to do.
    Regards, Merle

  12. Dear Merle: The idea of a health records software program that is shared between a person and his or her physician/medical home practice, and is also accessible for emergencies, referrals, and other uses consented to and controlled by the individual, is perhaps one whose time has come. It may become the cornerstone of Participatory Medicine by 2012 or so. I commend you for putting your version of this innovation into the marketplace, and I wish you well in your endeavors. You’re going to have competition!
    Please don’t assume that Brian Klepper and I are “ducking the issue” of health data and information availability to doctors. What we’re saying is that EMRs and EHRs that conform to administrative top-down criteria for certification ought not to be the ONLY solutions to creating, managing, and exchange of personal health information found worthy of federal subsidy under the new Obama administration. And our short list of alternatives was just that — very short, not intended to be exclusive. I think the ideas that you represent in your post are innovative, and also deserve attention and study. Thank you for offering them.
    Very kind regards, DCK

  13. Your analysis of what’s wrong with EHRs is on the money but your solution—to ignore the problem and look elsewhere for ways to improve care and reduce costs—ducks the issue.
    There is extensive evidence, both anecdotal and in studies, that a physician equipped with a patient’s complete medical record is more likely to avoid making a medical mistake and ordering unnecessary tests than if he/she doesn’t have it. Put another way, would you rather your physician have your complete medical record when he/she treats you? Physicians I’ve talked with tell me that if they had a patient’s complete medical record, they “could practice better medicine.” Thus, I consider it essential that we solve the problems surrounding personal health records—and we are doing just that.
    The place to start is to ignore today’s “conventional wisdom” that all care providers must install EMR/EHR systems, that all patient records be stored on Web servers and accessible over the Internet, and that government agencies and non-profits should subsidize both the adoption of EHR/EMR systems and the construction of Internet networks such as RHIOs, HIEs and the NHIN. (I should add that we have no argument with physicians adopting EMR systems. I hope they do because it would make our life easier. I simply don’t want to get hung up on such a requirement because we can achieve our objective of creating a comprehensive personal health record—what we call a Lifetime Health Record™— even if physicians keep paper records.)
    Our company, Health Record Corporation, has developed a different approach to personal health records that meets the needs of both care providers and consumers. One leading authority describes it as “a consumer-driven medical record idea that makes sense.” It satisfies consumer concerns by storing a patient’s records on a portable device the consumer owns, controls and carries or wears, not on Web servers. It employs established technology and transcends the technical issues troubling EHR/EMR vendors. It is its own repository and makes a patient’s records immediately accessible to care providers when they treat the patient (the patient merely gives it to his/her care provider thereby fulfilling the function of a network: moving information from where it resides to where it is needed). It allows physicians to maintain either paper charts or electronic records as they wish. Physicians are paid to upload copies of a patient’s records to it; a typical PCP can increase his/her annual income by $25 thousand or more. Physicians can electronically sort and search its contents thereby accessing the records they need. It can be implemented in 12 months rather than years. It improves physician workflow. It is financially self-sustaining and doesn’t require subsidies. It is relatively cheap; it doesn’t cost hundreds of billions of dollars—but it can save billions. (If every Medicaid patient used the MedKaz™, we conservatively estimate the states would save more than $6 billion.)
    Anyone interested in learning more and/or working with us may wish to visit our corporate and product Web sites, healthrecordcorp.com and medkaz.com. I would love to hear from you.
    The long and short of it is that there, indeed, is a simple solution to personal health records. All we have to do is take off the blinders and embrace it!

  14. We are far from the goal that President Bush set to provide EMRs for most Americans by 2014. The overwhelming evidence is that not only is high cost a barrier, but also the disruption caused by implementation, the complexity of usage models, and the fear that systems become obsolete due to lack of interoperability. So at this tipping point in healthcare’s future, the incoming administration must be unfailingly realistic in how to truly progress the industry. To bring about tangible, achievable change in healthcare, we must:
    1. Utilize technologies that are practical, profitable and efficient for physicians to use in their daily workflow. This means solutions that:
    o Are accessible and affordable for practices of any size to implement.
    o Are adoptable by physicians and/or their staff without extensive training or practice redesign. Additional benefits may accrue to those who do use technology in exciting and disruptive ways, but basic benefits should be achievable for modest change.
    o Enhance care services, improve efficiency and bring additional revenue back to the practice, even in the form of incentive payments or changes in reimbursement. We must align incentives with desired changes in behavior to create a sustainable economic model.
    2. Enable the mobility of data – between providers, between patients and providers, and across the healthcare eco-system. For too long the focus of HIT has been on the storage and manipulation of the data. The explosive power of technology that has reshaped other American industries (travel, financial services, consumerism, B2B commerce, journalism) has been in unleashing the power of available data by enabling access and mobility – via email, portals, transactions, search and so on. Each of the examples you cite (ePrescribing, eReferrals, eVisits) combine the existence of data with the mobility of data to create an improved outcome.
    3. Are truly interoperable, for continuity of care regardless of the technology platform within a physician office. While all initiatives to improve interoperability are applauded, we must not let the desire for what’s possible get in the way of what’s practical. We must move the entire industry forward by taking advantage of technologies that offer a basic level of interoperability, that work in a PM-based practice, or in one with an older or “light-weight” EMR, and don’t require dedicated and complex transport protocols for moving the data in and out of the practice. As your article suggests, let’s focus investments here on the basic infrastructure of DSL, Cable and Cellular connectivity and enable high-speed, high-availability email and internet services on which pragmatic solutions already run.
    The technology to support these requirements for progress exists today. These everyday technologies allow for immediate collaboration, improve patient care, increase patient engagement and remove error and inefficiency in the process, moving the industry forward – without the sticker shock.
    We encourage federal investments to focus on incentivizing the desired outcome, as is the case with the Medicare ePrescribing payment, to drive the right IT investments. The healthcare industry must learn to walk before it can run. Fortunately, the technology is already here to support healthcare every step of the way.

  15. Dear Roy: I think the problem for legislators and their staffs is that they feel they understand the idea of EHR. It’s been well packaged, and the lobbyists for health IT are very smooth. They’re good at what they do, and I respect them for that.
    What we need to do is make some of the alternatives to EHRs just as understandable, and to bring up the current limitations of a “just EMR” strategy in the context of a set of goals that includes care coordination, access, continuity, and good communications.
    My closest friends in the EHR/EMR industry are quietly applauding this approach, because they know they will sell a lot more product if and when there is widespread demand for ALL kinds of health IT, not just EMRs. And they understand network effects: interoperability increases the value of every node, and the more nodes that can connect on the network, the greater the economic value of the network.
    Thanks for your comment. Regards, DCK

  16. David, Brian,
    it takes a lot of “huzpa” to craft such letter but I deeply believe the two of you are doing this industry a very big favor. Its time someone stood up and advised washington that saying “EMR” 5 times a day isn’t enough to modernize the system. Worse than that, it exempts our legilator from the need to map out what else technology can do outside the obvious. Specifically, we need to consider how information technology can be used to redistribute access to medical services, not only for moving medical information around. When heading into the biggest healthcare reform in decades, we need to survey the possibilities of the future, not only the mantras of the past.
    Kudos, to both of you.

  17. Maggie’s trepidation about the corruptive effect of money (more accurately, profits) in health care is understandable, but the difficulty is that neither money nor profits is really the problem – economics is. And the stuff of economics – issues of allocating scarce effort/energy/initiative/resources – inevitably has a place in any human endeavor.

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  19. Maggie: Hear, hear! Let’s put the regulatory decision-making back into the hands of people who have no financial ties with the industry being regulated. What a revolutionary thought. ‘)
    Seriously, you and I agree. Now, how about also recruiting people who actually know what they’re talking about? Actual domain experts with track records of success.
    Seems we can do this! DCK

  20. It seems pretty clear that hospitals and institutions should not be allowed to “own the data”.
    This competition between hospitals is part of the problem with profit-driven, market-driven healthcare.
    (In most European countries, hospitals would never be able to get away with this. See Don Berwick on hospital’s claiming that what they know about how to treat a particular disease is “proprietary data.”
    This is an area where government regulation could be very helpful, forcing hosptials to collaborate, sharing EHRS for individual patients as well as databases that could be useful in
    developing guidelines on comparative-effectiveness.
    Healthcare Reform should aim to create a healthcare
    system designed to benefit the Patient. Right now, we have a heatlhcare system designed to benefit those who profit from the system– hospitals as well as IT vendors and drug-makers.
    David– when I talk about government regulation, I’m not talking about regulation designed by corporate lobbyists. For the last 8 years–lobbyists have been running Congress in a very open way. We have forgotten what good government looks like.
    But there are people in the Obama administration- Peter ORszag and Jared Bernstein come to mind–who understand what it would mean to have an SEC that actually regulates Wall Street, an FDA that puts safety and effectiveness first, and a Health IT czar who is insulated from lobbyists– perhaps someone appointed by the Comptroller (as MedPac is), with a panel and staff that has no financial ties to the Health IT industry. (Perhaps composed of people who were involved in developing “home-grown” systems at places like Geisinger, Mayo and the VA.)
    Money corrupts. And the more I read ad learn about healthcare, the more convinced I am that for-profit institutions will always put money–and the interest of their shareholders–first. This has no place in medicine.

  21. Self server wrote:
    “fact– zero evidence health IT systems save the system money.
    fact– health IT CAN save money on individual encounters if outside records make repeat tests unnecessary, or acute treatment more timely
    fact– health IT maintenance is UNBELIEVABLY expensive for all settings, even more so in smaller settings where redundancy and alternatives are not readily available.”
    I think he is right. I worked with both paper records and EMR in various hospitals since 1999. EMR can save money by preventing redundant testing/consultations, and more importantly, improve quality of care since all users have access to old tests (however, it can be time consuming esp. but not exclusively in the introduction phase, and I also urge EMR enthusiasts to consider the pediatrics article he mentions). It therefore does little good if a small practice has a little insular EMR. However, it works very well when systems are big enough like in my current 700+ physician MSG (or even better, if systems were connected). I cannot comment on maintenance being “unbelievably expensive” other than the fact that I am used to seeing a legion of very smart, likely high paid people do daytime service/trouble shooting and at times nightly (midnight no 2 am) maintenance … so he may be right on that, too.
    From following the discussion and my own experience, I see that a nationwide EMR could be done two ways:
    1) quick, brutal and relatively affordable by just scanning and filing all documents (for instance, all medicare and medicaid notes) and lab test results on a secure server.
    2) complex, expensive and with a lot of potential, by making EMRs intraoperable.
    Solution 2 seems to be the one advocated by Dr. Kibbe. I wonder whether we would get much more bang for the buck with option 1.
    In any case, I see some exaggerated EMR euphoria, a hope that clings no to the EMR as the messiah of the US health care mess, while other countries such as Canada, Germany, France etc. are doing much better without EMR (or with EMR in its infancy). I feel that EMR is a good investment that definitely would improve care and MIGHT save some costs even short- to midterm (by reducing avoidable duplicative testing), but it is not the savior of the dysfunctional US health care system.

  22. Sherry,
    You nailed it!
    “The challenges with interoperability have very little to do with standards actually. In in some of the major markets (Palo Alto, Seattle) you have the same vendor at multiple hospitals (PAMG, Kasier and Stanford) who can’t exchange data. The vendors know that their customer is the hospital not the patient who moves across systems and since Hospitals want to own the patient there isn’t a “business case” from the hospital to share the data but it isn’t difficult to do from a technology standpoint (Epic and MUMPS not withstanding) and everyone should be able to share the CCR critical patient information soon. Just as a reminder, Internet XML standards actually evolved pretty organically and followed rather then preceded adoption. You simply need to aligning business drivers with the technology.”
    When you extend your analysis to the fact that the large institutions and their vendors dominate the federal government sponsored standards selection efforts, it’s crystal clear why we are nowhere after all this time, effort, and money on standards. Hospitals and institutions want to ‘own’ their data and their patients and vendors want to ‘own’ and protect their market share. It is the exact polar opposite of moving patient data to facilitate patient care and patient safety. It is also, from a technologist’s perspective, criminal that a community like Palo Alto, the heart of technology innovation on the Internet and data exchange is frozen in the 1980s in health care IT implementations at its institutions. What a comment on where we are!
    Thanks!

  23. One commenter emailed this directly to me: “I believe that your suggestion to move concretely along points of least resistance and the greatest positive impacts for patient care (especially morphing onto free or low cost applications) is exactly the way to go. I think focusing as well on broadband/WMax architecture (in general, not simply for health care) is an extremely wise investment as we search out ways to create efficiency in sectors rocked by financial chaos. Connectivity = Efficiency and Quality Simultaneously (if applied strategically).”
    This brings up an area that Brian and I did not discuss in adequate detail in the blog post above, namely health IT investments that could be made on the patient/consumer side, the Health 2.0 dimension. The Internet and Web have made consumer-directed wellness and health care a reality in the same way that they have spawned consumer-directed journalism and the blogosphere. Perhaps there are investments in Health 2.0 technologies — online care and coaching software, to name a couple — that the Obama administration could well consider along with monies spent to make the traditional health care providers more effective and efficient through IT innovation.
    Regards, DCK

  24. Sherry: I think your points are very well taken, and nicely described, too. “Aligning business drivers with the technology” is a good way to sum up what Brian and I are after in this piece, and it’s also a wise observation that standards generally follow the adoption curve, not precede it (with a couple of exceptions that are noteworthy). Regards, DCK

  25. Excellent and very timely post Kibbie and Klepper! I hope that share this as part of the Community Health Care Forums that are occurring all across the US in the next two weeks for the new administration.
    Maggie and Rick – Many of the systems like Kaiser and the VA that were the first to implement large EMR’s are also closed systems so that the “savings” in cost or increases in quality accrued right back into the system instead of going out the door to the insurance companies so the business model is different and there needs to be a shared investment model used to bring all of the stakeholders (including large employers and the government as a payer who are self insured and could drive this).
    There is also a different need for information for different populations (healthy wealthy, chronic conditions, young moms) and therefore vastly different products that can meet those needs over someones lifetime and there isn’t a one size fits all scenario.
    If we focus our HIT investment on the 10% to 20% of the population with multiple chronic conditions that account for 70% of the health care spending we would have less impact on work-flows, increase outcomes and have a larger impact on cost control. This needs to be coupled with changes i work-flow at the same time (ie add case managers, medical home, change the reimbursement from medicare to compensate for care mgmt) otherwise all you are doing is giving people an electronic pencil that lets them document poor care electronically.
    The challenges with interoperability have very little to do with standards actually. In in some of the major markets (Palo Alto, Seattle) you have the same vendor at multiple hospitals (PAMG, Kasier and Stanford) who can’t exchange data. The vendors know that their customer is the hospital not the patient who moves across systems and since Hospitals want to own the patient there isn’t a “business case” from the hospital to share the data but it isn’t difficult to do from a technology standpoint (Epic and MUMPS not withstanding) and everyone should be able to share the CCR critical patient information soon. Just as a reminder, Internet XML standards actually evolved pretty organically and followed rather then preceded adoption. You simply need to aligning business drivers with the technology.
    Were any of you given incentives to use email to talk to your colleagues across the industy? This is a given for patients and once they have been in a system where they have it as well as real time online access to lab results (like Group Health where some practices 25% of visits are via email) patients will insist on it across the board. Those drivers will have far more impact on HIT adoption then government incentives alone but CMS is the largest purchaser and could move the process along.
    Sherry Reynolds
    Allinace4Health

  26. I think the Nancy the nurse’s comments might be the most realistic of all the comments posted here. I used to work in a neighborhood clinic in which they had installed an EHR system a year before I started working there. The thought was that it would increase flow and communication. Unfortunately it did the opposite and they had about $200,000 in unresolved bills because of some minor errors in the superbill execution. The EHR system they had chosen wasn’t the best system, but it was the cheapest (it was a low-income clinic). My point is that the system was far from intuitive and everyone working in the clinic was too busy to learn how to use it correctly. There was no one trained as the onsite “EHR Expert” and the only help the EHR company offered was expensive telephone help. Which, for the price of the system, is scandalous! I came in as a temp worker (with a Humanities degree!) and was able to figure out the system and the bugs and got the money flowing. BUT, it took me a good 3 months to figure it out and to communicate the problems to the physicians, nurses and physician assistants. There has GOT to be a more intuitive way of doing things. I hope you don’t mind my two cents, I just think it’s so important to listen to the EHR users. Although I did enjoy all the interesting perspective on EHR systems.

  27. Maggie: I think you’re making a good point, but we need to dig deeper…both of us. What health IT standards are appropriate for the government to mandate, and which standards ought to be left up to the market and the industry to establish and use? I don’t think this question should be approached from an ideological stand point. We should carefully consider this question from within some framework. We have to admit that we don’t yet have the framework completed.
    And what do we mean by “the government” in this case? Are you suggesting that lobbyists and big corporations who have the most money and muscle to influence governmental agencies, task forces, or panels should be given carte blanche to set health IT standards? (Pretty much what has happened in the last 6 years.) I don’t think you’re saying this, right? On the other hand, Rick and I are not suggesting that market forces have complete sway over health IT, either. Where’s the right balance? We criticize Microsoft for being monopolistic, but we are also danged thankful that they created a standard operating system, because it led to hugely less expensive personal computers. There are many such examples, and in general I don’t think the government has done a very good job lately. Perhaps that will change. Many thanks for your comments. dCK

  28. Rick–
    Thank you very much for a very helpful response.
    If it’s okay, I plan to quote you (and Brian and David) in a post I’m writing for HealthBeat, linking to this post. How do you identify you? (You can e-mail me at mahar@tcf.org)
    The only point where I’m not quite persuaded is with regard to standards– all I can say is that in countries that have working EHR (Sweden, etc.) govt was key in setting standards.
    Also, I can’t help but think how messy the introduction of cellphones was in the U.S. All of the roaming fees. . . By contrast, in Europe, a top-down decision was made, and European could use ther cell phones in many countries. . .
    Finally healhtcare isn’t music files, hairspray or computer chips (David’s examples) or Facebook or Google.
    It’s a necessity–like electricty or water. This is why
    I tend to think that standards should be set by government and that, in order to make healthcare as affordable as possible, any vendors should be non-profit. . . .

  29. Thanks Rick, J Bean, and Nancy Nurse: I’m so glad to hear the voice of a nurse in this discussion, because in the real world of health care it is the nurses, along with other non-physician staff, who do most of the computing and software use. And she’s right on: nurses bear the burden of customized software implementations that are almost unique to the hospital or practice that uses them. In my experience, this situation hasn’t helped interoperability or data sharing progress at all.
    On the standards issue, I have to agree with Rick. The government may be acting appropriately to set reporting and regulatory standards, as does the SEC for banking and the IRS does for taxes. But our society would scream in unison if the government stepped in to set standards for online display, music files, computer chips, or hairspray.
    The problem isn’t a standards problem: it’s fundamentally a problem of unwillingness to use standards by important and powerful vendors. Provide their customers with a business incentive for greatly expanded data sharing and communication, of the kind we’re discussing here, and those customers will quickly convince the vendors that standards are the way to go. Regards, DCK

  30. As a working nurse it seems to me that a big part of the problem with EHRs is that deals are made between vendors and hospitals without finding out the real-time processing needs of the care giver. Nurses are strongarm-educated to learn a system that is welded together from the vendors current offering. EHRs will succeed only when they are designed by the persons who do the work.
    I am suspicious of ideas that suggest that EHR development should be driven by absentee stakeholders.

  31. I agree with almost everything you say Rick, with the exception of the establishment of standards. There needs to be at least an industry arbiter of standards, some sort of quasi-governmental organization analogous to the IEEE.
    It would be healthier for the medical informatics industry, if interoperability standards got sorted out sooner rather than later. This is a young industry that has repeatedly burned its early adopters. It’s no wonder there is resistance to switching over to EMR/EHR. The current product is expensive and it sucks. Like Ford, GM, and Chrysler have discovered, it takes years to overcome a bad reputation.

  32. Maggie,
    Just a quick note on your comments:
    1) Some of the best EHR systems are self or internally developed and they meet a certain specialty or individual practice or institution very well, but they seldom scale in terms of functionality, configurability, or technically. Even if they do scale, the hurdle they need to climb to gain any market share is far too steep. The classic RFP has the criteria, ‘How many installations do you have?’ which is deadly. The sad thing that this is such a complex and slow moving market most but not all products with wide distribution are actually hopelessly antiquated.
    2) Yes, I’m biased, by I agree that clinician and work flow designed systems are best. Much of the cost, time consumption, complexity of implementation of EHR systems is that they are not only too complex themselves, they actually make the practice of clinical medicine less efficient than it was on paper. Advocates say this is the price you have to pay to get data in a computable form, but those advocates do not tend to be in the trenches. A good EHR improves efficiency, decreases tasks and redundancy, and simplifies rather than complicates workflow. Too much of our EHR efforts to date (and I take personal responsibility for my own role in foster that) have been focused on structured documentation. Bad idea, but that is an entire discussion on its own. It is ALL about work flow and improving provider and team efficiency and patient safety – sadly we missed that.
    3) Should the government set interoperability standards and is that more efficient than market competition? I believed in government intervention but three things have changed that. First, HIPAA – great idea for claims interchange but completely undermined by the EDI vendors and clearinghouses. Even the payors wanted it to work and we all watched it crash and burn. Second, unless government is willing to be completely open in its standards efforts and safeguard the process so it is not dominated by government itself or the dominant market players we will end up with HIPAA again – good intentions all around, but a complex standards set that is undermined by the established vendors who want to protect market share. Third, no other major industry uses government regulation or mandate to set interoperability standards. Reporting standards such as the SEC are another matter and are appropriate, but interoperability in this day and age is open source and driven by the market. Look at social networking – Google and Facebook have competing standards and vendors comply with both. Facebook or Google might want to ‘win’ but the rest of industry just needs to exchange profiles and messages. Both Google and FAcebook standards have opened up the social networking world – see Google’s announcement about Twitter, et. al.
    4) What do we learn from the integrated multi-specialty centers that are successfully using EHRs? We learn a lot, but how applicable is it? First, they have more money than God and are spending way too much for what they are getting in my opinion. Second, the workflow and clinical efficiency data coming out from them is discouraging – provider and clinical efficiency has been negatively impacted, not improved. The large institutions can absorb this and make an assumption that the ‘better’ data they get will compensate in the long run. That might be true but smaller practices cannot take a 10 to 20% hit in practice productivity and expect to make it up some other way. You would be lucky to pick up 5% in improved charges and claims accuracy, but you are already underpaid 5-10% so you’re screwed. Lastly, few if any of our large institutions are implementing state-of-the-art technology. Their criteria are that these systems have to be tested and proven. That is too bad, because the big players can afford to take the risk and work on the bleeding edge.
    Kibbe and Klepper have a good perspective on this. EHRs still (and this is so painful for me to say) have a very, very long way to go before they are ready for prime time.

  33. Thanks for this post.
    I’m far from an expert on Health IT,
    but what you say makes sense.
    It seems clear that we’re not ready to
    roll out EHR on a national scale.
    Though I have
    to say, when I saw my new 50-something
    eye surgeon the other day, I was very impressed
    by the EHR system he has. He as able to show
    me the results all of the test he had done so efficiently–photos of my optic nerve, print-outs
    of other tests, and he was so nimble with the
    system (as is everyone on his staff) He has
    trained them all himself.
    I asked him if he had a hard time learning to
    use the system, and he said he couldn’t remember, it was so many years ago(more than a decade). He added that he developed the system himself and
    owns part of the company.
    But clearly he’s unusual, especially for his generation–and a genius in more than one way. Still his example did strengthen the argument that these systems should be designed by clinicians , not IT specialists. What do you think?
    Maybe I’m wrong, but eventually,
    it seems to me that the
    government will need to set standards for
    interoperability and cost rather than letting
    private contractors compete in the hope that
    a solution will emerge from the competiton.
    (Such a messy and expensive way to do something
    like this.)
    Also, what can we learn from the integrated multi-specialty centers that are successfully using
    EHRS? (Geisinger, Mayo . .)

  34. David-
    fact– zero evidence health IT systems save the system money.
    fact– health IT CAN save money on individual encounters if outside records make repeat tests unnecessary, or acute treatment more timely
    fact– health IT maintenance is UNBELIEVABLY expensive for all settings, even more so in smaller settings where redundancy and alternatives are not readily available
    I just wish that for once there would be some true intellectual honesty: health IT is good because the technology can make some people’s life better (both patients and providers, including hospitals) but it will cost a TON– and the early builders of the infrastructure, whether they be venture capitalists or the taxpayers, will almost NEVER see a return on the investments…
    meanwhile, the people who make money on the process will do quite well.
    and, unless I am wrong, you fit into the last category.
    This is neither accusation nor indictment— simply facts.
    You would do well to mention the main peer-reviewed paper from Pittsburgh that showed greater errors with an EMR. (http://pediatrics.aappublications.org/cgi/content/abstract/116/6/1506)

  35. Drs. Kibbe and Klepper raise many important and timely issues.
    I believe what they are saying is that although they agree with, as I do, that the December 6, 2008 goals of President-elect Obama, expressed in parentheses in their Open Letter, that our healthcare delivery and related processes be connected through the internet, they do not believe that simply providing every provider and facility with an EHR or EMR system as these products currently exist will solve the first priority need of integrating communication and data exchange between providers, patients and facilities.
    Indeed, President-elect Obama’s well respected pick to head the OMB, Peter Orszag, Director, Congressional Budget Office, in testimony before the Senate Finance Committee, July 18, 2008 said:
    “The bottom line is that research does indicate that, in certain settings, health IT appears to facilitate
    reductions in health spending if other steps in the broader healthcare system are also taken to alter
    incentives to promote savings.
    By itself, however, the adoption of more health IT is generally not sufficient to produce significant cost savings.”
    I hope Mr. Orszag recites these words to President-elect Obama and takes heed.
    I know from first-hand experience that the installation of an EMR system is a several year commitment of dollars and time, mainly time away from patient care by provider and staff alike.
    Now if this sacrifice were to achieve the stated goals of inter-provider-patient-facility communication and data portability it is worth it, but, that is not the opportunity we have today with current systems.
    I believe most of the new money to be injected into healthcare IT should be spent on developing and supplying the broadband channel as the Drs. state as well as on a National Web-based Healthcare IT Network that provides the infra-structure to connect any smart EHR system or dumb desktop terminal together in a distributive network. Such an open network could also provide a host of down-loadable med- apps or med-lets for many simple care functions that Drs. Kibbe and Klepper suggest such as Referral Management, Patient Communications and E-prescribing. Think of the iphone and the open-source applets.
    Such a system will open healthcare IT to commerce in general and provide thousands of IT jobs. More importantly, however, it would create a healthcare IT univers that is uniformly integrated and compatible, unlike the disparate collage of EHR systems currently offered for sale today to currently unwilling and broke providers.
    An example of the problems non-integrated EHRs bring to healthcare delivery is in the area of managing chronic diseases, for example diabetes.
    Most manufacturers of EHR systems gloat over the fact that their systems have ‘templates’ for every chronic disease, or worse, that every provider-owner can create their own chronic disease template.
    Correct me if I’m wrong, but in a world and at a time when there are well established standards of care for diabetes why do we want every doctor treating diabetes according to his or her own personal nuance?
    Perhaps, this care-chaos, driven in part by EHRs inherent capacity to endow doctors with care-creativity and in part to simple mal-care derived from the fact that most doctors have not even read the ADA or ACCE Standards of Care for Diabetes much less have the time or ability to implement them properly and completely is responsible for the $175 billion we spend on diabetes and the $90 billion of that wasted on the unnecessary complications of diabetes associated with poor care.
    Here again is where a National Web-based Healthcare IT Network could, through a diabetes med-let structure, organize, and deliver all of the complex subroutines necessary to manage even basic diabetes care.
    Finally, let us finally rid ourselves of our thinking that there is a healthcare delivery system-there is not, only a disparate patchwork of dueling entities, or that there is a medical profession-there is not, or when we think of healthcare delivery we think of some organized uniform set of providers-there is not, or there is a home for a medical home.
    As for a medical home the only answer is a virtual medical home, another possible feature of the National Web-based Healthcare IT Network.
    As for a healthcare delivery system, whether we get one remains up to what Obama’s Healthcare Team comes up with. A system is sorely needed; the answer most likely is a Universal one.
    As for healthcare delivery, who do you think is serving up the care? Well, here is a partial list: medical doctors, alone or in groups, self-employed or employed, or as is mostly the case de-facto employed as in having no fee schedule, just getting whatever Medicare, Medicaid, insurers, and the HMOs decide, Concierge docs, mid-levels such as Pas and NPs, Doctors of Nursing “the nurse, oops, doctor will see you now”, Family Chiropractors-including both the Pediatric Chiropractor and the Doctor of Neurology Chiropractor, the pharmacist prescribing, or soon to be prescribing, ‘behind the counter drugs’ such as statins and antibiotics, the Minute Clinics of the world, and did I say, the Internet, to just name a few.
    Do we need an integrated IT-based system of care with this kind of care-diversity? I think so.
    Finally, any sarcasm from medical doctors is understandable, but lacks sympathy from me.
    Medical doctors, me included, have no one but ourselves to blame for our economic and professional dilemmas.
    We were too lazy and apathetic to organize to prevent insurers from taking over our profession and seeing to it that it was dismantled. When we relinquished our right to bill for our services we broke our covenant with Hippocrates and abandoned our patients. For that we should be held accountable.
    Louis Siegel, M.D., December 15, 2008, http://www.LikeADoctorInTheFamily.com

  36. Great comments, thank you for taking the time to write them. Lots to think about….As for XML, in speaking about health IT that is “interoperable” we’re discussing a limited, but important, set of clinical, business, and technical issues around process improvements required for medical care management to become more effective and efficient in the 21st century. First, we’re going to deal with health information traveling over networks; all kinds of networks, not just those that are private or organizationally bound. What is of interest to us here are the emerging standards and best practices for inter-organizational as well as inter-personal transport of data using the Internet. Secondly, we want to consider sets of health data and information that are simultaneously both human- and machine-readable; that is, data structured in such a manner that common digital document formats can be applied — so as to make them easy to render and read as web pages, pdf documents, or plain text — and that are also structured for computability without human intervention. This involves the general purpose XML representation of clinical data. Thirdly, the content of the messages being transported will be clinically relevant and capable of being used to support many different kinds of decision support, including at the point of care as well as aggregation for retrospective analysis and research. Finally, we have to acknowledge that the business case for the technology that will enable, encourage, and support these productivity-enhancing informatics tools and methods are largely lacking in our current and broken health care system in the U.S. This entire area is a disruptive innovation to which there is significant pushback and resistance from incumbents.
    But no question that XML is the most important standard here. Regards, DCK

  37. It would seem the government could further assist by establishing a set of standards for the EMR\EHR systems that are minimums for acceptability. De facto they have already started this by pushing the web based (browser based) solution. Currently each vendor wants their piece of the health care dollar and is trying to bring us the tools we need\want but still lock us into their solution. An open set of standards would help either force them to play well with other applications or to try to go it alone without necessarily requiring consulting contracts for us.

  38. It would also be a mistake the make EHR physician-centric. We need a broader system that is person-centric so people can manage all the information relevant to the events and behavior that affects their lives. Health 2.0 and Medicine 2.0

  39. Dr. Kibbee: I think it is reasonable to ask ourselves if we can to better as a nation. Its almost 2009, we are in the middle of an economic crisis, and a new President elect. Maybe we as a nation need to take a step back and “sharpen the saw” so to speak. I think you are on point when describing how
    e-prescribing being the closet thing to a working model. Is HIPAA really understood? Is it helping or hurting American healthcare? I don’t know but, refactoring is usually a good thing.
    Anon: You make a very good point about liberating billing codes.
    Patients should be able to use online and other services and health care providers should be able to be paid for these services.
    My point is we are all talking about the same problem. Unlike in e-prescribing, there are no “formularies”. We need a path for automatic claim adjudication for most all diagnosis, procedures, medical equipment, and more. This will help consumer adoption. If we are going to ask Mr. Dashel to open up the codes, then make sure all the codes are made available to every American.
    We need to create open and shared set of exchange tables that define a set of rules to automatically process most claims. The key word is open. Can we imagine a way to create an open health marketplace where procedures/care and prices are known to everyone?
    I’d offer Tom Daschle and President Elect Barack Obama the following use case to achieve that would signify major progress.

    Jan Patient goes online. Jan can search, by procedure code, for doctors in her area. Prices for procedures are clearly seen and related services, if any, are also displayed. Jan’s coverage information is immediately available because she supplied her payer and plan. Jan can even look over her coverage details based on procedure code(CPT), DRG codes, etc. Jan’s physician has access to the same information and utilizes it to automatically adjudicate the claim and receive payment for services. Everyone can immediately see what is covered what is not. Everyone knows what the procedure costs are and how it cost and benefits change when a particular provider and payer intersect.

    This would mean real comparison shopping potential for consumers!In a brainstorming session a few months back I drew up a simple XML schema for such an exchange. (In case any fellow computer geeks are reading this)
    Bottom line is we need open “formularies” everywhere. not just for drugs. I realize automatic claim adjudication can’t happen in every instance but even an 80/20 split would make the whole system more efficient.

  40. Babel can easily be a avoided with a standard format like XML. This would give us (the developers) a required set of fields to include in the EMR. XML would simply be the translator that sits between to applications that are speaking different languages.
    My company provides simple, and super affordable web based applications as a service. I currently have completed a visit tracking system that will allow home health agencies to track which staff member visits which patient. It includes visit details and billing details. Since it is on the web, the patients, doctors, nurses, and just about any person you choose to authorize can see these details. This opens up communication between the doctors practice, the home health agency, and the patient’s family.
    Is it affordable? $25 per month is affordable without government aid. I beleive the medical and educational sectors are light years behind in Internet technology that is why I started my company. $40,000 is insane. Most clinics do not need a huge application that’s does more than they need. The medical needs simple solutions that require no training and are easily introduced to the workflow. The best web based solutions replace multiple tasks in your workflow while also sharing secure information.

  41. Dear self server: I hope you’ll take another read of our modest proposal. We agree with your point that spending tax payers dollars on health IT, especially expensive and complicated health IT systems, could be a boondoggle for consultants. (That is your point, right? Hard to tell through all the sarcasm.)
    But you miss our point. Simple, incremental, and low cost health IT doesn’t require consultants at all! Physicians and their staff can figure out how to use secure email, e-prescribing, and e-referral apps without or with very little training, and since they are all web based, without consultants to set anything up in their offices.
    As to government contracts for consultants, the same argument is valid. If the government policies stick to promotion of wise business cases linked to better care and which call for appropriate uses of health IT, then there should be no need for consultants. On the other hand, by getting involved with the choosing of IT products and standards through bodies like CCHIT, the governments sets itself up to require consulting contracts left and right.
    So, despite your sarcasm, I think we’re on the same side of this position, yes?
    Regards, DCK

  42. Dear anon: I think you completely mis-read our words, anon. We’re suggesting what you (presumably a busy doctor) want, namely fair compensation for patient care management that is not “volume based” but “value and quality based.” The idea here is not to make doctors do things for which they’re not compensated: rather, it’s to move the payment structure away from fee-for-service and towards reward for coordination, continuity, and communication — that is what we all want. (It’s also, to be fair, not our goal to make doctors rich, but rather to take better care of patients.) An incremental management fee for e-referrals or e-mail communications could be a win-win-win, with better more convenient care for patients, more time with better informed patients for the docs whose time is valued, and lower costs for whomever is paying the bills. And it would not require large up-front investments in complex IT software that doesn’t deliver these benefits, or does so only very slowly.
    Regards, DCK

  43. and please, please President Obama—
    do not forget our names when you pass out government contracts to push all this technology…
    for while we believe the greedy doctors, the vicious insurance companies, the dysfunctional hospitals, and the incompetent private business sector should see health care delivery as a right for all, and really a ‘calling’ that should require the entire sector to be not-for-profit…
    the consultants who provide wisdom and advice from on high (that is us, by the way, just in case you are very busy– or even smoking while reading this) about the implementation of this fabulous technology just simply cannot do so without a significant margin of profit built in to our contracts.
    Remember Mr. President, you will get what you pay for– and we’re really good.

  44. Dr. Kibbe,
    email access for patient communication is not helpful unless the provider can bill for using it, otherwise it sets up yet another patient expectation to interact with their provider in a fashion for which the provider will not get paid.
    The counter-arguement is that email is more efficient than phone calls. Well, given the choice to work for free less efficiently or more efficiently, most have chosen not to work for free at all and do laser hair removal instead. Until the payment system is changed even simple IT augmentations will fail to maximize their potential.
    I have a better idea, use some of that IT money to liberalize the codes that allow me to bill for case management. You don’t need some “medical home” program to do it, just tell Tom Daschle to make the requirements for submitting existing codes less onerous. It worked when they did it for nursing home codes two years ago. Who knows, some medical students might actually go into primary care.

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