The Cost Cutting EHR

Healthcare Information Technology (HIT) and Electronic Health Records (EHR) are at the heart of health care transformation. Everything we want to change and improve upon, hinges on the availability of EHRs in every hospital and every physician practice. We all know that EHRs can improve quality of care by providing evidence-based, patient-centered clinical decision support at the point of care, while measuring outcomes and customer satisfaction, so we can monitor and reward providers for their efforts. But this is not nearly enough. After all, our current health care crisis is not due to hundreds of thousands of citizens succumbing en masse to shoddy medical practices as much as it is due to having to squander 17% of GDP on pampering Americans with unnecessary, excessive and way too technologically advanced diagnostics and therapies. We must cut health care costs or perish. There could be an EHR for that. The following is a blueprint for transforming any EHR into a cost-cutting machine guaranteed to chop health care costs in half in less than one year of use.

Cost Awareness – There’s been much discussion lately revolving around small studies showing that when physicians are made aware of costs, they order fewer tests and save the system money, and it was suggested that EHRs can help place costs of everything in front of ordering providers. Absolutely. There is a tiny problem with obtaining true costs, as opposed to arbitrary prices, but in this era of Data Liberacion, surely we can summon the liberation of all insurance negotiated fee schedules. The innovative computer geeks can take it from there, and if we are missing some numbers here and there, we can make them up just as well as hospitals do. Armed with these data, the CPOE module will display the cost for every test about to be ordered, in a very patient-centered way, since we know what insurance the patient has. This in itself should also reduce disparities since Medicaid pays so much less for everything that we can easily order twice as many tests for Medicaid patients, for the same cost to society. Just so patients don’t feel disempowered, patient portals should clearly display tests and procedures costs as well. We could show the costs to their insurer, but a more deterring shock value would come from displaying the hospital list price, so patients can be better prepared in case the insurer decides to deny payments.

Subliminal Messaging – Well, yes this is illegal for advertising, but it should be acceptable for the public good. For providers, we should have two types of subliminal messaging in the EHR. Prospective messaging would flash inducements to order generic drugs for example. A more sophisticated and patient-centered strategy would be to tailor the message to the individual patient. So if, say, the EHR knows that the patient is there to discuss his PSA test results, and the EHR knows what the results are, it could flash “wait and see” all through the visit. Careful programming is required here to ensure that messaging occurs only on provider screens. Retrospective messaging could be used to create feelings of guilt and regret if providers order an MRI. It is likely that they would want to avoid these feelings in the future. We could integrate subliminal messaging into patient portals to help reduce utilization. For example, in the scheduling module, we could flash the word “NP” for consumers attempting to make an appointment, so they are guided to less extravagantly priced resources. Although this particular feature must be written from scratch, the potential for code reuse is obviously enormous. I’m sure pharmaceutical and device companies can come up with great ideas as well, but please remember that for marketing purposes, this is illegal, and no, this is not an infringement on commercial free speech.

Spending Counter – In the olden days when EHRs were mainly good for billing, some used to have funny little counters that showed physicians (there were no providers in those days) how much they made so far today based on selected E&M and CPT codes. Those widgets were not very accurate, and not widely used. Well, here’s a chance to reuse that old code or write new one if we must. As providers go through their daily work, the counters will add up how much health care money each particular provider has spent, in real time, and display the cumulative amount on every EHR screen (much like those page visit counters on the web).  As we gain more experience with value based benchmarking, the spending counters can become interactive. Each day spending limits could be preset per provider, adjusted to reflect schedule complexity, and the counter will run down all through the day as patients are seen and orders are placed. As the counter approaches zero, we could implement popup alerts to notify providers that the end is near. When the spending counter hits rock-bottom, the CPOE module is disabled and no further orders can be placed without administrative override. We can reduce spending limits by a few dollars every week and like Milo of Croton, providers won’t even notice the gradual cost efficiency achieved over time. To foster healthy competition, we could display other providers’ spending status too. The larger the group practice, the more competition we can foster.

Patient Centered Spending Counter – Upscale EHR vendors who are marketing their products to Accountable Care Organizations (ACO) may want to personalize the above counters for each patient. These widgets should display on the summary page for every chart and on each screen where the patient is in context and be represented by an hourglass graphic image. Since the ACO will be receiving claims data from other providers, we could easily calculate how much was spend on each patient during the current fiscal year and compare to what the ACO projects that should be spent to maximize shared savings. To assist providers at the point of care, an info button should be added that will provide clinical decision support when the hourglass gets low on sand. For example if the patient already had six office visits this year, the software may suggest sticking to e-visits and secure messaging for the rest of the year. It is very important to display this counter in patient portals as soon as the consumers log in, so they can judiciously manage their personal flow of sand. The ACO may wish to offer small, Sand Savings rewards to consumers who end the fiscal year with a surplus of sand in their hourglass.

Break the Plastic – Many EHRs, particularly those designed for inpatient care, have a “break the glass” feature which, in an emergency, allows physicians to access medical records of people who are not their patients. Physicians are given explicit warning that such access will be logged and audited and often these events are indeed audited by administration. The EHR code used to implement this functionality can be easily modified to support adherence to evidence based medicine and assist providers in keeping unreasonable consumer demands at bay. For example, if a provider caves in and attempts to prescribe an antibiotic for a documented diagnosis of common cold, the EHR will pop up a dialog screen with a red stop sign icon saying that this action cannot be completed. The provider may then show this screen to the consumer and hopefully he/she will just go away. If the consumer insists and the provider is talked into changing the diagnosis and trying to prescribe the antibiotic again, the EHR will pop up a different alert stating that the documented positives do not match the new diagnosis, but if the provider wishes to proceed and “break the plastic”, the event will be logged and audited by the committee to discover the reason for changing a diagnosis after trying to prescribe. Hopefully the consumer will take pity on the provider by now and go spend his own money on a Theraflu generic at Walgreens.

Consumer Digital Signature – Most EHRs today have nifty little checkboxes that allow physicians to acknowledge that they provided counseling to patients on a variety of issues. Since we know that a lot of money can be saved by providing consumers with counseling on smoking cessation and weight management, for example, we need to be certain that such counseling was indeed provided in earnest. Who better than the consumer to attest that sufficient counseling took place? All we need to do here is implement existing code for digital signature, usually written for the provider e-prescribing module, and add it to the progress note page. If satisfied, consumers will enter their special credentials, a simple PIN should suffice, at the end of the encounter. Other than saving money by improving lifestyle behaviors, the EHR can keep count of counseling sessions and automatically deliver a small punishment to consumers who show no positive changes in behavior. For example, a smoker who digitally signs 3 cessation counseling sessions, but is still documented as a smoker on his fourth visit, may see his Sand Savings reward disappear. Small rewards and punishments have been shown to consistently improve wellness and save money.

As outlandish as these features may seem, they really are quite easy to implement in a robust EHR. The only complex development consists of the various real time interfaces with insurers to bring claim data into the EHR, which is really nothing more than reversing the current interfaces that send claim data out to payers. As health information exchange matures in the next couple of years, and more and more data is liberated, many different cost cutting, personalized features could be added. Unlike the first generation of EHRs, widespread adoption should not be a major problem since most providers will be employees of large systems and accustomed to following policies and procedures. Judging by the growing spirit of innovation in Health IT, it may also be easy to find young entrepreneurial companies to quickly build this type of widgets and integrate them into existing EHRs for a fraction of the cost of proprietary development. These are exciting times.

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

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19 replies »

  1. Confesso che avrei voluto dire io quanto afferma la Prada su Maria Jos猫 e non l fatto per non pestare i piedi a quanti l eletta, Maria Jos猫 intendo, anacronisticamente partigiana, anche in questo caso con totale mancanza di memoria e verit脿 storica. Mentre da noi le prime pagine di tutti i quotidiani prendono di mira il ‘molleggiato’, e si dovranno ancora vedere i settimanali, in Gran Bretagna accade la stessa cosa con Sean Penn. Fulmini e saette piovono in testa all’attore americano proprio come qui sulla figura di Adriano Celentano.

  2. I understand the professional component of the service. But surely whoever gave you the tent and stethoscope, is capable of calculating the cost of tents, stethoscopes and whatever they pay you for your service.

    “Doctors don’t know what their services cost to deliver.”
    This is not acceptable. Doctors know what they need/want to get paid, and they know (if in private practice) what the overhead is. It takes a simple calculator to do the rest. Every profession calculates these things. Granted the needs/wants are a bit elusive, but that’s where expectations and market conditions come in.

    There was a time, before the AMA decided that competition is evil, when doctors did compete on price for their services.

  3. Doctors negotiate with payors for the highest price they can get. Doctors don’t know what their services cost to deliver. If I am in a paid for tent and I have a patient, a paid for pen and a paid for stethoscope, it looks like I could provide an office (tent) visit for five bucks. Is that what I am worth? What if I had an auction for twenty appointments per day. What would it bring per visit? What do I do with empty appointment slots? Lost opportunity is a cost to me.

    Fact is, medicine was not built like Wal-Mart, to sell for less. Medicine was built to provide the best no matter the cost, no matter the price. Then in 1983 the struggle to reign in government payments began. And here we are.

  4. Many think that “EMR/EHR” are simply born with the DNA to cut down transcription cost.
    Many others think that “EMR/EHR” can be futile to the growth and future of transcription jobs.
    Some others think that it is a combination of the two that makes EHR/EMR a deadly mix… What is your take?
    Quotations may be attributed incorrectly. This is an unedited edition of “Let the People Speak. All quotations have been previously made available to the general public. This free resource may be re-quoted with the following attribution

  5. How about supply? Why don’t we have enough doctors on the market that they will compete on price and drive prices down that way?
    Why is the supply of doctors regulated and constrained in very complex ways?

  6. The patient is not going to be satisfied in the future, given the inevitable cuts from the government. I will be on the front lines. The Congressman will not be there. The President will not be there.

  7. Don’t confuse price with cost. Prices are per item. There need to be a decrease in the number of items demanded.

    The cost of healthcare is demand driven. The price per item needs to be market driven. The patient needs to determine the demand based on the value to them, the patient.

    The patient needs to determine the value of his covedrage, and purchase what he values with money that is not kept by the employer.

  8. Not that I agree, but if only the patient can change the cost (the price really), and you don’t care about the patient’s satisfaction, then how can the patient change the price?

  9. This is nothing more than HMO on steroids. Didn’t work before.

    Only the patient can change the cost, by demanding less.

    Nothing in an EHR changes the standard of care. Indemnify me from lawsuits. Make malpractice a systemic cost like worker’s comp, rather than a tort process, and you might get somewhere on the doctor side.

    Eliminate Press-Gainey scores and I won’t have to be worried about “patient satisfacton”.

    Until then I can’t get no satisfaction.

  10. Just in case anybody thinks that this type of intrusion in pure sci-fi, here is a real one from Florida as it appears on the AAFP news page:

    “The Florida measure, H.B. 155, which is expected to become law, would prohibit physicians from intentionally entering firearms ownership information into a patient’s medical record. It also would prohibit physicians from asking their patients about firearms ownership unless the physician “in good faith believes that this information is relevant to the patient’s medical care or safety or the safety of others.”

    The bill also prohibits physicians from refusing to accept patients based on whether they own firearms. And it gives patients a way to complain to the state medical board about physicians who ask them about gun ownership. Physicians who violate the provisions in the measure can be sanctioned and disciplined by the state medical board.”

  11. I’ve been using EHR’s for over two years now. Now, I know I am a younger doctor than many others, but it does save money and time if done correctly. I know this isn’t directly on topic, but it helps and its more clear.

  12. You won’t have to MD as HELL, at least not any time soon, and not because of this….

    Yes, Mike, this was intended as entertainment…well, sort of….

    However, this illustrates how technology with minimal effort can uniformly apply controls to any workflow. Although I don’t believe things will deteriorate to this extent, I do think that physicians’ professional judgement will get seriously fenced in by dollar signs.
    Since doctors are not voluntarily ordering less and patients are not willingly asking for less, and nobody else wants to take a hit, somebody, either government or Nate’s friendly insurers (with government’s blessing) will eventually step in, and technology is the perfect tool for stepping in..

  13. The problem with computer “warning signs” is that after a while, when they become so commonplace, users really don’t appreciate the meaning behind them. How many times have you gotten some computer-issued message that you’ve seen a thousand times over, only to ignore it once again?

    The punishment idea might work better, but Sand Savings? Does anyone other than people being interviewed on daytime television news shows actually use reward points? How about using those uber-popular rubber bracelets, imprinting the word “HEALTH” on their surfaces, and equipping them with electric shock emitters that are always more than just an annoyance? I think you get the picture.

    It’s time to move from the computer “warnings” into a new age of digital-physical warnings, ones that have some real teeth to them. Maybe those teeth are made out of some metallic alloy, but the day the robots come to liberate us from our foolish overspending on something as trivial as health care, the sun may shine once again. That is, if the the robots deem sunlight good for our health.

  14. A mix of reasonable and truly horrible ideas!

    Cost awareness? Yes of course.

    Subliminal messaging? I do hope you are joking. The one thing I count on my physician for is to apply rationality to the problem of my health. Can you seriously imagine that a physician would accept a machine that attempts to undermine reasoning (or even to support it) with subliminal messages? I certainly don’t want a physician who would accept that. If an idea is good enough to be considered it should be weighed by the conscious mind.

    Spending counter? Oh please be joking! If I have an appointment late in the day, my care is going to be limited because the doc already spent for other patients? Tradeoffs on spending have to be made across the entire practice or population, and surely, surely, should not depend on who happened to come in on the 20 visits before me, or even in the month before me. Allocation decisions cannot depend on the time frame in which a patient shows up.

    Patient centered spending counter: OK, sounds reasonable.
    Break the plastic: OK
    Consumer digital signature: OK

  15. My understanding is that all these features will be required in Stage III Meaningful Use.