Tag: EHR

A Healthcare Information Services Provider Business Model

Jan 5, 2011• 8

By JOHN HALAMKA, MD

I’ve written previously about Healthcare Information Exchange Sustainability and the need for Healthcare Information Services Providers (HISPs) to serve as gateways connecting individual EHRs.

How should HISPs be funded and how can we encourage HISP vendors to connect every little guy in the country?

We’ve started to think about this in Massachusetts.

There are numerous vendors promising HISP services – Medicity (Aenta), Axolotl (Ingenix), Surescripts, Verizon, and Covisint.

An HIE needs to include at least one common approach to data transport, a routing directory, and a certificate management process that creates a trust fabric. Existing HISP vendors have heterogeneous approaches to each of these functions. In the future, the Direct Project may provide a single approach, but for now HISP vendors will need to be motivated to adhere to State HIE requirements.

An idea that has been embraced by some State HIEs, such as New Hampshire, is to pay HISP vendors a modest fee (under 100K) to support State requirements. This “connectivity” incentive results in interoperable HISPs, creating a statewide network of networks.

Once a standardized HISP approach is supported by multiple vendors, then individual practices need to be connected. Some practices will be aggregated into hubs by EHR software vendors as has been done in cities such as North Adams (Massachusetts), projects such as the New York City PCIP project, and physicians organizations such as the Beth Israel Deaconess Physicians Organization. However, it’s not likely to be cost effective for a vendor to connect every isolated practice to a HISP for the $50/month the practice is willing to pay.

Failure is Not an Option

Dec 30, 2010• 78

By MARGALIT GUR-ARIE

2010 is drawing to an end amongst a flurry of activities in the Health IT field. In a few short days 2011, the year of the Meaningful Use, will be upon us and the stimulus clocks will start ticking furiously. In addition to the yearlong visionary activities from ONC, December 2010 brought us two landmark opinions on the future of medical informatics. The first report, from the President’s Council of Advisors on Science and Technology (PCAST), recommended the creation of a brand new extensible universal health language, along with accelerated and increased government spending on Health IT. Exact dollar amounts were not specified.

The second report from the Institute of Medicine (IOM) is a preliminary summary of a three-part workshop conducted by the Roundtable on Value & Science-Driven Health Care with support from ONC, and titled “Digital Infrastructure for the Learning Health System: The Foundation for Continuous Improvement in Health and Health Care”. The IOM report, which incorporates the PCAST recommendations by reference, is breath taking in its vision of an Ultra-Large-System (ULS) consisting of a smart health grid spanning the globe, collecting and exchanging clinical (and non-clinical) data in real-time. Similar to PCAST, the IOM report focuses on the massive research opportunities inherent in such global infrastructure, and like the PCAST report, the IOM summary makes no attempt to estimate costs.

Make no mistake, the IOM vision of a Global Health Grid is equal in magnitude to John Kennedy’s quest for“landing a man on the moon and returning him safely to the earth” and may prove to be infinitely more beneficial to humanity than the Apollo missions were. However, right now, Houston, we’ve had a problem here:

The nation spent upwards of $2.5 trillion on medical services this year
Over 58 million Americans are poor enough to qualify for Medicaid
Over 46 million Americans are old enough to qualify for Medicare
Another 50 million residents are without any health insurance
The unemployment rate is at 9.8% with an additional 7.2% underemployed
This year’s federal deficit is over $1.3 trillion and the national debt is at $13.9 trillion

Between the Cracks

Dec 18, 2010• 5

By KELLY CHERAMY

Between the cracks is a frightening place to be.

During the course of trying to improve our family’s financial stability, my husband and I were blind-sided by one hidden detail: We’d face $10,000 in costs to continue my husband’s serious medical treatment because we found ourselves unexpectedly without coverage for 30 days.

This was money we simply did not have. We had been prepared to foot the full bill for good health insurance, but that wasn’t even an option, thanks to the circumstances of our career transitions and my husband’s health.

I was leaving my job of 10 years to begin a satisfying new position that came with excellent health care coverage. It was a beneficial move that would offset my husband’s impending loss of insurance as his employer downsized and prepared to go out of business. We knew the end result, but we didn’t know the timing. It just so happened that his coverage ended the same month that I began my new job, leaving a gap of one month before my new coverage would begin.

With this routine employment-benefits formality before us, we knew we’d have to purchase coverage. We had hoped to buy a Cadillac COBRA plan, given the circumstances that require very expensive care. But we learned that an out-of-business employer is not obligated to offer COBRA, and our plan to continue the same level of coverage at our expense was not available.

Sticker Shock

Dec 13, 2010• 18

By GRAYSON WHEATLEY, MD

It was supposed to be a routine office visit for my patient. Unexpectedly, it turned into a real-world health economics lesson for me, the treating physician. The old adage “listen to your patients; they will always give you the answer” became exceedingly true in this case, even when it dealt with an issue beyond a medical diagnosis, such as lack of transparency regarding insurance coverage for medical procedures.

My patient had recently undergone an interventional procedure to treat severe peripheral vascular disease in order to improve his leg circulation. Usually, patients like him don’t seek treatment for vascular insufficiency until the discomfort associated with activity, or claudication, is severe enough to interfere with their regular rounds of golf. That is the real motivator for these patients. The procedure was a success and a few days following the procedure he was back to his normal activities and was pleased that his leg no longer bothered him as he motored around the golf course.

My patient calmly waited until after I checked his pulses, reviewed his medications and gave him a plan for follow-up before he expressed his real concern, and it certainly wasn’t about whether he could now get an extra 20 yards on his tee shot as a result of the new strength in his leg. Despite my office obtaining all the necessary private insurance pre-authorizations for the interventional procedure, he still had received a bill for approximately $10,000 related to out-of-network charges. I was baffled and my patient was disgruntled about this mix-up. After reviewing with him in the examination room the numerous sheets of paper he had received from his insurance company, it became clear what had happened.

$978 American Dollars

Dec 9, 2010• 7

By JESSA HARFORD

On 4/29/10 I received a Mirena IUD. I thought about this a lot; I read forums and articles on the device and its side-effects. I decided that because I already have a beautiful son who is 2 years old with my wonderful boyfriend of 7 years and we do not need any more children at this point in our lives, that it would be a good idea. You see, we both have been unemployed for a little over a year now. And while on Unemployment we made too much to receive Medi-Cal for any members of our family. So, while on Unemployment I was paying about $300/month out-of-pocket in premiums for medical insurance for my son and myself. (My boyfriend thinks his body can heal itself.) Anyway, after paying $75 for the visit and only being in the appointment for about 30 minutes, and another $75 for a mandated follow-up appointment, I received a bill on 8/18/10 for $978. (That is 978 American dollars, just to clarify.)

As I stated, while I got this device I was paying out-of-pocket for my insurance premiums because I could not be approved for Medi-Cal. A couple months after getting the IUD both of our Unemployment checks stopped coming. We had no income. Zero dollars a month coming into our home. So I instantly went down to the DHA and applied for pretty much anything I could. I started receiving Medi-Cal for all 3 of us. (This was all before I got the bill, or knew how much it was going to be.) When I went to Kaiser’s Customer Relations Department they informed me that Medi-Cal would take care of whatever cost the IUD would be, but now that I have gotten this bill and spoken to them again, they are saying that they were mistaken when they told me that because I was not receiving Medi-Cal during the time I got the IUD.

The Cost of Care

Dec 5, 2010• 3

By NEEL SHAH, MD

On Labor Day Costs of Care asked doctors and patients to send us anecdotes that illustrate the importance of cost-awareness in medicine, as part of a $1000 essay contest aiming to shine a national spotlight on a big problem: doctors and patients have to make decisions in a vacuum, without any information on how those decisions impact what patients pay for care.

Two months later we received 115 submissions from all over the country – New York to California, Texas to North Dakota, Alaska to Oklahoma. We feel these stories are poignant because they put a face on some of the known shortcomings of our system, but also because they unveil how commonplace and pervasive these types of stories are. According to essay contest judge Dr. Atul Gawande, a surgeon and staff writer at the New Yorker, “These [stories] are powerful just for the sheer volume of unrecognized misery alone.” The following story from Brad Wright is one of the finalist submissions in our contest …

Three Ultrasounds

Dec 5, 2010• 24

By TARCIA EDMUNDS-JEHU

Sitting in an exam room I am watching my patient struggling to ask a difficult question that she clearly does not want to ask. After several attempts at starting and a few half finished sentences she finally manages to mumble a request for help with obtaining food for herself and her two daughters. She is a 41-year-old woman, 32 weeks pregnant with her third child, and working a full time job as a CNA in a local nursing home. Her husband is also working full time as a janitor. At her initial visit she denied any issues obtaining food for herself and her family, and declined any referral to social services.

“Has the work situation changed for you or your husband?” No. “Have you always had difficulty getting food and did not want to ask?” No. “Is there some reason you need more food than you needed before?” No.

Tears begin to flow and she starts to talk. She tells me that she had been in this country for 5 years and never had public assistance of any kind. She talks about her long hours working 2 and sometimes 3 jobs in order to have enough money to keep her family afloat. She talks about putting herself through school to become a CNA while still working to pay her bills. Until last year she was doing this alone, making not only money to provide for her family, but also the money needed to bring her husband here. She had never asked for help or let her children go without. But now she is unable to pay her bills and buy food. What is the tipping point for her ability to provide for her family?

Do EHRs Kill People?

Dec 4, 2010• 56

By MARGALIT GUR-ARIE

Back in the times when EHRs were just EMRs, they had a very simple and humble mission. The software was supposed to help providers of health care services better manage their business. EMRs were supposed to help physicians adhere to CMS documentation rules, automate patient flow management and get rid of all the mountains of paper floating around a typical medical office or hospital. It was assumed that EMR software will increase reimbursement rates, streamline workflow and even make the doctor more efficient. After all, every other industry that switched to computerized business management realized bottom line improvements.

Along the way, bolder statements started appearing, mainly from EMR vendors trying to sell their wares. EMRs could also reduce medical errors. The most common argument was for the benefits of replacing the notoriously illegible physician hand writing. Prescription errors would be reduced if only pharmacists and nurses could get a nice legible script. Then came the frequently misplaced paper charts. If the chart resides in the computer, it cannot be misplaced, it is always available to all and it is complete. All the information you need right at your fingertips, regardless of your physical location. It could save lives or at the very least, it could save time. The EMR was nothing more than an electronic chart. One vendor went so far as to create a computerized image of a yellow manila folder with tabbed pockets for various items in the electronic chart.Continue reading…

If I Ruled the World

Dec 4, 2010• 23

By DAVID DRANOVE, PhD

If you study previous attempts to reform healthcare delivery through the private sector, there is one common thread. These attempts all failed because of an absence of proper management information systems. We need integrated electronic health records. And not just to improve medical decision making. We need EHR that can be used for management decision making – for contracting, measuring costs, measuring and rewarding quality; I could go on and on. We are trying to solve management problems in a $2 trillion industry using management information systems that would be an embarrassment in nearly any other sector of the economy.

Of course, the industry has been pushing EHR for decades and there are places where EHR is really first rate. Kaiser is a great example but also a special case because of its thorough vertical integration and long history. And even Kaiser has been unable to replicate itself outside of its core markets. The sad fact is that most providers have little incentive to adopt EHR, and even when they do, they have little incentive to be compatible with other providers. Unfortunately, the network externalities benefit purchasers and consumers a lot more than they benefit providers, so don’t expect the compatibility problem to solve itself.

My proposal is simple. Assemble a panel consisting of medical professionals, managers, and insurers. “Lock them in a room” for 72 hours and tell them to choose from among the many fine existing EHR systems. Tell them they can combine the best features of each if they wish. Once we have settled on an EHR system, give every provider one year to adopt it. If they refuse, deny them Medicare and Medicaid payments. Combine the stick with a carrot – subsidies to providers who have limited financial resources. I believe the total one-time subsidies would be less than $50 billion, a drop in the bucket compared with the size of the system.

Blood Test Surprise

Dec 3, 2010• 24

By BRAD WHITE

In the spring of 2005, the sinus infection returned. I awoke severely congested with a pounding forehead and pain around my eyes that grew worse when I bent to tie my shoes. The feeling was familiar. Two years earlier, I had similar symptoms, but was uninsured and endured a miserable week with nothing but over-the-counter medication. Now they were back.

Fortunately, when I started graduate school, my father insisted that I have health insurance. As a healthy 24 year old, I didn’t see the need, but he agreed to foot the bill for a high-deductible insurance policy to cover me in the event of catastrophic illness. Except for four physician office visits subject only to a $35 co-payment, my policy offered no benefits until I spent $3,000 out of my own pocket. With my sinuses throbbing, I knew I needed to use one of those visits. Overwhelmed by the list of “in-network” providers on the insurer’s website, I picked an internist based on convenience—his practice was located in a medical complex near my home.

Arriving for my appointment, I checked in and presented my insurance card to the receptionist. “Your visit today will be $35,” said the woman behind the desk. I was relieved to hear that my coverage was working as promised. A nurse ushered me to an exam room, where the physician promptly entered, half-heartedly listened to my complaint, and confidently asserted that I did not have a sinus infection because I had no fever. I wanted to say “Really? Mind handing me a tissue so that I can show you what’s been coming out of my head?” but resisted the urge. Instead, I clarified that fever or no, I didn’t feel well, and believed my sinuses were the culprit. At this, the internist lost patience. He ordered some lab work and a sinus CT scan to rule out infection, and said that I could have everything done downstairs.Continue reading…