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Learning From Our Interoperability Failures

flying cadeuciiCurrently, when healthcare data moves in this country it does it using fax machines and patient sneaker-nets. Automated digital interoperability is still in its earliest stages, mostly it has a history of being actively resisted by both the EHR vendors and large healthcare providers. We, as an industry, should be doing better, and our failure to do so is felt everyday by patients across the country.

The ONC-defined difference between EHRs and EMRs is that EHRs are interoperable. Yet, as I have said before, we have spent almost a billions of dollars and generally gotten EMRs instead of EHRs.

Comments were due Apr 3 for the ONC Interoperability Roadmap for 2015-2020. This was specifically separated out from the overall ONC Health IT Strategic Plan for which comments have closed.

Both of these plans ignore the lessons in execution from the previous strategic plan for health IT from ONC. The current Interoperability Roadmap mentions the “NwHIN” (Nationwide Health Information Network) for instance, and only covers what it accomplished, which are mostly policy successes like the DURSA (Data Use and Reciprocal Support Agreement). NwHIN was supposed to be a network of networks that connected every provider in the country… why hasn’t that happened?

ONC has forgotten what the actual ambition was in 2010. It was not to create cool policy documents. The plan 5 years ago was to have the “interoperability problem” solved in 5 years. The plan 5 years before that was probably to solve the problem in 5 years. Apparently, our policy makers look at interoperability and say “wow this is a big problem, we need at least 5 years to solve it”. Without any sense of ironic awareness that this is what they have been saying for decades, even before Kolodner was the ONC.

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A Business Proposal for Mark Cuban

Businessman and maverick, Mark Cuban recently opined “if you can afford to have your blood tested for everything available, do it quarterly so you have a baseline of your own personal health.” I’m unsure why he said quarterly, not weekly, daily or hourly. ‘ 

He further opined that this must be done to “create your own personal health profile and history. It will help you and create a base of knowledge for your children, their children, etc.” I assume etc. refers to grandchildren’s children.

I’m unclear what my grandchildren would gain from knowing my serum free testosterone levels in 2014. That’s a lot of data to enter in ancestry.com. For that matter, the size of my grandfather’s spleen in 1956 probably doesn’t affect the way I think about my mortality. That year he had a bout of Leishmaniasis, which, thankfully, isn’t a problem in Philadelphia.

Cuban further explained “a big failing of medicine = we wait till we are sick to have our blood tested and compare the results to “comparable demographics.”

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An Epic Struggle for the Soul of Medicine

Martin SamuelsThis week I attended an all day “training” session in a new medical record system.  I thought it was interesting that the experience was called “training,” which prompted me to remind myself of a few useful definitions.

Education, from the Latin root meaning a drawing forth, implies not so much the communication of knowledge as the discipline of the intellect; an intra-cerebral process aimed in large part at creating principles upon which new knowledge may be elaborated.  Instruction is that part of education that furnishes the mind with knowledge.  Teaching is often applied to practice as in “teaching a dog to do tricks.”

Training is an element of education in which the chief characteristic is exercise or practice for the purpose of imparting facility, as in “training for the marathon.” Breeding relates to manners and outward conduct as in “standing when elders enter a room is a sign of good breeding.” Regimentation is the prescription of a particular way of life or thinking usually involving the imposition of discipline. The term, arising from military regiment, is related to the medical usage of regimen, as in “the patient keeps his prescription medications in separate compartments of a plastic container in order to accurately adhere to his regimen.”  Propaganda is the systematic propagation of a doctrine, cause or information reflecting the views and interests of those advocating such a doctrine or cause, as in “ACCME is propagating the view that elaborate re-certification maneuvers will improve the lives of patients.”

A cheerful instructor started the session by asking each of us to introduce ourselves and reveal a “secret guilty pleasure.”  Mine is to create elaborate cocktails.  If only I had had one of my famous Marty’s Beerjitos with me the whole experience could have been much more pleasant.  In addition to the instructor, there were several “super-users” in the room to facilitate the process.  It was immediately obvious to me that the super-users hovered behind my chair. These friendly young people had correctly identified me a “super-loser.”  Had I been litigious I would have reported the experience to our ombudsperson as blatant ageism.

But, alas, they were correct.  I was hopeless.  Besides, I don’t believe in ombudspeople.  I believe one should speak for oneself.

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Will Independent Physicians Go Extinct?

Richard Gunderman goodLife is tough for physicians in solo and small group practice.  The federally mandated introduction this fall of ICD-10 requires physicians and their staffs to learn a new system of coding diseases.  “Meaningful Use,” another federal program, requires physicians to install and use electronic health records systems, which are complex and expensive.  And PQRS, the Physician Quality Reporting System, is beginning to penalize physicians for failing to report individual data for up to 110 quality measures, such as patient immunizations, each of which takes time to collect and record.

Of course, such requirements are not being imposed solely on solo and small-group physicians.  In many ways, they affect all physicians alike.  Yet the burdens of complying are disproportionately high for small groups, which cannot spread out the costs of purchasing equipment, hiring employees and consultants, and training personnel over so large a number of colleagues.  Hospitals and large medical groups can afford to hire full-time specialists to meet these challenges, but such approaches are not economically feasible for a group that consists of only a few physicians.

Such challenges are not just raining down –  they are pouring down on the heads of physicians.  Some physicians fear they smell a conspiracy to drive solo and small-group practitioners out of business.  And the problem is not just the money.  It’s also the time.  Many physicians already work long hours and simply cannot afford to shop for such systems, negotiate contracts, and enter data.  We personally know physicians who report spending two hours each evening completing records that they did not have time to attend to while they were seeing patients.

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Precision Medicine’s First Real Patient: The National Health IT System

Niam YaraghiIn his 2015 State of the Union address President Obama announced the launch of his precision medicine initiative, an audacious initiative to address these issues. In a nutshell, precision medicine customizes health care; That is, medical decisions are tailored based on the individual characteristics of the patients, ranging from their genes to their lifestyle. To have a clear understanding of the relationship between individual characteristics of patients and medical outcomes, it is necessary to collect various types of data from a large population of individuals. The precision medicine initiative requires a longitudinal cohort of one million individuals to provide researchers with various data types including DNA, behavioral data, and electronic health records. Assembling such a large sample of many different data types proposes two unique challenges pertaining to healthcare information technology: interoperability and privacy.

The federal government has already spent $28 billion to incent medical providers to adopt electronic health record (EHR) systems. As a result, almost all of the medical providers in the United States currently compile an electronic archive of their patients’ medical records. However, most of the EHR systems are not able to exchange information with each other. This is a strange problem in the age of information technology and Internet connectivity. There are a variety of technical and economic reasons, which make it especially complicated and difficult to solve.

Given the current lack of interoperability between EHR systems, it seems highly unlikely to be able to obtain a complete medical history of one million Americans. To succeed, the precision medicine initiative has to either overcome the lack of interoperability problem in the nation’s health IT system or to find a way around it. Congress members in both the House and Senate are considering new rules that would stop EHR vendors from interfering with medical providers that had already started transferring records. These efforts are fraught with difficulty and will take a very long time to produce tangible results.Continue reading…

What Does Real Meaningful Use of an EHR Look Like?

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I drank the kool-aid early.  We installed our first EHR in 1996 with me doing the lion’s share of pushing and pulling.  While I’d ultimately turn my back on this passion, I had a number of notable accomplishments before walking down my Damascus road.

  • Within a year of implementation, our practice became one of the top installations for our vendor.
  • Within 2 years I was elected to the board of our user group.
  • Within 4 years I was president.
  • In 2003, our practice was recognized by HIMSS as one of the top primary care installations of Electronic Records.
  • In subsequent years I lectured around the country (for HIMSS) extolling the benefits of EHR for both quality and efficiency of care.
  • As opposed to the experience of other physicians, our practice was not only successful in our implementation, we were in the top 10% in income for our specialty.
  • Our quality metrics were also routinely far above national norms.
  • In 2012, I was the physician representative for CDC public health grand rounds, discussing the upcoming EHR incentive program: Meaningful Use.
  • By 2013, we easily qualified for stage 1 of Meaningful Use, and I happily accepted the financial fruit of my labors.

But the final years were not, as I expected, a triumph. I became increasingly frustrated with the worsening of our EHR by the “features” needed to qualify us for MU1. I also chafed at the way most physicians were meeting this criteria: by abandoning patient-centered care and adopting a data-centered care model.  Patients were given useless handouts to summarize “care,” and the data requirement was satisfied.  Patient portals gave limited access to information were touted as “patient centered” care, while the product was left unused by most patients, but the data requirement was satisfied.

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On Mandatory Screens and the People Doing the Screening

Art Caplan 2The entirely predictable media obsession with the tragedy of the Germanwings jetliner that crashed into the French Alps on March 25 is moving forward full force. The media, especially cable television, love airline disasters. Once German prosecutors revealed that Andreas Lubitz, the pilot at the controls of the Germanwings jetliner when it crashed, had a mental illness but had kept the diagnosis hidden from his employer, all media hell broke loose.

One of the key questions raised by the spectre of mental illness was whether the pilot’s doctors tried to establish Lubitz’s mental fitness to fly and if they were concerned should they have revealed their worries to his employer. Despite a whole lot of talking heads jawing on these points few had anything useful to say since almost none of the experts consulted seemed familiar with the accuracy of mental health screening, or with the nature of German requirements for health screenings for crews or mechanics, or with German privacy law. When the discussion shifted to what about America, things still stayed fuzzy.

Pilots being interviewed noted that the Federal Aviation Administration requires they receive a physical exam from a flight surgeon annually or every six months as they get older. What mechanics or flight attendants undergo was never mentioned. Mental health is supposed to be a part of the exam for pilots but it almost never is. Pilots and the doctors examining them know that any indication of mental illness including addiction or suicidal thinking would get reported right to the FAA and that would be the end of that pilot’s job so little probing gets done. Plus those doing the screening rarely have any training in mental health.Continue reading…

The High Cost of Reducing Waste in US Healthcare

thcbRecently, a jury awarded a young California resident $28.2 million for a delayed diagnosis of a pelvic tumor. The jury found Kaiser Permanente (KP) negligent. Doctors in the system, touted to be one of the finest systems by the President, allegedly refused an immediate MRI for back pain in a 17 year old. The patient eventually received an MRI three months after presentation, which found a tumor so extensive that the patient needed an amputation.

The case is instructive at multiple levels. It shows a tense dialectic between the individual and society. It also highlights a truism that many don’t understand or don’t acknowledge – missed/ delayed diagnosis and waste are reciprocal. They’re birds of a feather. You can’t have less of one without more of the other.

The patient presented with back pain. MRI for back pain is the poster child of waste. Why so? Because so many are negative. Even more are meaninglessly positive –disc bulges which simply mean “I’m Homo sapiens and I wasn’t intelligently designed to be sitting at the desk.”

High quality doctors don’t order MRI for back pain immediately, reflexively and incontinently. Think about this. A high quality doctor should say “I don’t think you need an MRI because it won’t change the management and doesn’t improve outcomes.” That’s the resounding message from the top. If it doesn’t improve outcomes it’s not a worthy test. High quality doctors will, once in a while, cost their organization a lot of money.

But quality is still not settled. Quality doctors must satisfy patients. If a patient asks for an MRI for back pain the quality doctor must acquiesce, if that refusal dissatisfies. I’m confused. Ordering an MRI for back pain is poor care. But not ordering an MRI for back pain is poor care. Which is it?

We don’t know the facts of the case. It’s possible that the patient had a neurological deficit that should have raised the urgency. It’s possible that the physician didn’t examine the patient and had he/ she examined, the tumor might have been detected. We don’t know. We shouldn’t judge (1).Continue reading…

Accountable Care: Transparency of Fees Is Mandatory

thcbA personal account of a transaction that went very badly, and rules of Health Reform were not followed.

Accountable Care and associated transparency have not made it to Florida, at least not in this physician’s office.

I made an appt with an ENT (ear nose and throat doctor) for ear wax.  When I get there, I need to fill out 5 papers (EMRanyone??), and I’m told there is a $35.00 copay, which she says I can pay on my way out.

The 5 page HIPAA form says they can share my info with other providers who are trying to collect fees. But you only learn this, among other clauses, if you read the form that is tacked on the wall–it’s not in the form the patient signs.

I asked the receptionist how much the office visit is, and she said, “On your insurance there’s a $35.00 copay.” Yes, but is there an additional fee for removal of ear wax? How much? “We can’t tell you that until after the doctor sees you and marks what is done. And besides, we don’t know if you have satisfied your deductible.”  I tell her I have not, but because I have to guarantee payment if the insurance company denies anything, I’d like an estimate of charges.  She repeats the deductible statement and I say yes, I understand, but that’s a problem, as I haven’t satisfied my deductible so I need to know how much this will be. She tells me she will get the Office Manager (OM).

The Office Mgr (who is disguised in a clinical suit) tells me, “You have to sign this financial form before the doctor sees you because after, you will have received the services so you or the insurance company owe the money.” No problem say I, but I need an estimate, and I can’t sign a financial responsibility form that allows you to bill me if my insurance company doesn’t pay you in 45 days AND that tacks on a 30% interest fee, when I don’t know if I can afford it.

Two visits into the doctor’s lair, she comes out and says, “Dr M is more than willing to provide the services you need but he cannot be interrupted to tell you the costs of the services.” BOOM.

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The Health Care Blame Game

Nortin HadlerOvertreated, overstaffed, over-administered, overpriced, over-regulated, and over-legislated: that’s for starters. How about over-diagnosed, over-medicalized, over-screened, over-digitized, and over-litigated? Then there’s unavailable, inaccessible, non-empathic, and even cruel when it comes to the disabled, disallowed the disaffected and the disavowed. To top it off there’s the American fashion of dying, alone and encumbered by the machinery of futility.

Political pundits and policy wonks point fingers at the mainstream American health care system, sometime more than one finger, often at more than one putative culprit, and often by partisans within the system. It’s open season.

Then there’s the off-off-campus American health care system decrying the on-campus system as insufficiently holistic, alternative, complementary, organic, nutritious, mindful, centered, and soothing. Worse, still, the mainstream is decried for being dismissive of the various therapeutic modalities that various practitioners believe to be essential to maintaining health and restoring well-being. The on-campus Health Care System is so dismissive of these “others” as to wield the “sectarian” label and to restrain their licensure as much as political pressures countenance.

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