Tag: Richard Reece

Health Reform: Evidence-Based Medicine and the Real World

The July 7 edition of the New England Journal of Medicine just arrived. It contains two back-to-back articles that illustrate the problems of transforming medicine into an evidence-based format.

• The first is “Lessons from the Trenches – A High Functioning Primary Clinic.” Its author, Thomas Bodenheimer, MD, a well-known University of California academic, describes the workings and make-up of Clinica Family Health Services, a Denver-based primary care community health clinic. The clinic serves 40,000 patients at 4 sites. Fifty percent of these patients are uninsured; 40% are on Medicaid. Clinica aspires to be one of the first Accountable Care Organizations. Each of its locations includes three primary care practitioners, three medical assistants, a RN, a case manager, a behavioral health professional, and medical-records and front-desk staff. The clinic “has moved boldly from a doctor-based model to a team-based model.” Patients are never turned away, and most are seen on the day they call. The 4 clinics have a linking EMR, and they concentrate on assembling data that show progress. These data includes time it takes to see a primary care doctor or to meet with “the team,” entry to care during 1st trimester, number of low birth rate infants and % of Cesareans, Pap test within last 3 years, number of patients with diabetes and their glycated hemoglobin levels, and number of patients with hypertension. The goal is to improve all these measures. The basic idea is to serve patients while retaining loyal clinicians. The next step will be to reduce ER visits and hospital admissions. This step “awaits a new funding stream, which requires participation in which Clinica will share savings from reduced downstream costs.” To which I say, “ Good luck.” Many observers, including myself, say Accountable Care Organizations are DOA.

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The Usefulness and Uselessness of Electronic Medical Records

Nothing is so useless as a general maxim.

Lord MacCaulay (1800-1859), On Machiavelli (1827)

I dare say that I have worked off my fundamental formula on you that the chief end of man is to frame general propositions and that no general proposition is worth a damn.

O.W Holmes, Jr. (1809-1904), as quoted in The Practical Cogitator, 1962

The general maxim and general proposition behind the rationale of a national interoperative electronic medical record system in every physician’s office is that you can never get too much information and that government can use digital data to cut costs and improve care.

The Problem

Sounds good, doesn’t it? The problem is that so far, after nearly a decade of advancing this maxim and proposition, perhaps 80% of physicians in independent practice aren’t buying. And this, in face of the reality, that government has proposing spending $27 billion to get EHRs off the ground. And beginning this year, CMS will start offering as much as $44,000 per physician over a staggered five years if physicians make “meaningful” use of “certified” medical records. Many doctors regard such rhetoric as empty talk that will accompanied by unreasonable bureaucratic requirements, as surely as dawn following night.

Why no “buy-in” among doctors? Why have two national IT coordinators appointed by Obama, David Brailer,ND, in 2005 and David Blumenthal, MD, in 2011, resigned in frustration over the failure to persuade doctors that gathering electronic data and measuring care is a good thing? If universal EHRs are such a good thing, why have physicians and hospitals not raced to embrace EHRs?

As Steve Lohr of the New York Times, a leading thinker in health care innovation, says in yesterday’s Times (“Seeing Promise and Peril in Digital Records,”

“What is beyond doubt is that the promise of digital records will be unfulfilled if doctors refuse to adopt them, because they regard the technology as cumbersome, time consuming, and possibly dangerous.”

To date, most doctors, except for enthusiastic early adopters, IT nerds, and those in large organizations, have found EHRs “useless” in their daily work. EHRs cost excess money, show little return on investment, change the very nature of practice, slow productivity, tell no narrative tales, cause conflicts among staff and colleagues, require extensive record keeping, are subject to hacking, and, more often than not, are useless as a tool for communicating to colleagues, hospitals, and other doctors outside your practice.

When the government establishes “usability standards” that work, maybe doctors will come on board the electronic train. Until then, says Dr. Edward H. Shortliffe , a professor at the University of Texas Health Science Center in Houston, “Usability is going to be the single greatest impediment to physician acceptance. “

If EHRs are not made more useful and soon, universal digital records may turn out to be a giant boondoggle rather than a scientific bonanza.

Richard L. Reece, MD, is pathologist, editor, author, speaker, innovator, and believer in abilities of practicing doctors and their patients to control and improve their health destinies through innovation. He is author of eleven books. Dr. Reece posts frequently at his blog, Medinnovation.

Why Do We Trust Doctors?

The National Journal has released a Special Report. The Report features a series of  four articles: Restoration Calls – Fixing America’s Crumbling Foundation. Among these articles is: “Why Do We Trust Doctors?”  It contains results of a Gallup poll, showing trust in doctors is at all-time high of 70% over the last ten years.

This is intriguing considering numerous media articles on physician personal profiteering and physician partnerships in technologies such as imaging equipment  for financial gain.

The article begins, ”We’re cynics about insurance companies and critics of big health companies.  So why do we still believe in physicians?”

Why indeed?  The author of the April 26 piece, Margot Sanger-Katz, tells the story of 60 year old Mary Morse-Dwelley of Maine who has undergone 22 operations to close an abdominal incision and who has had her gallbladder, uterus, and 2 feet of intestine removed.  She has spent two years in bed. Despite this long surgical ordeal, she implicitly trusts her surgeon. So does the American public, if you believe Gallup.

When patients are asked why they trust doctors, patients say they see doctors as someone who is trying their best to help them. They do not see them as agents of government, insurance companies, or institutions. They trust the interpersonal face-to-face relationship and the motives of their doctors.

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Why Doctors Don’t Like Electronic Health Records

Why are doctors so slow in implementing electronic health records (EHRs)?

The government has been trying to get doctors to use these systems for some time, but many physicians remain skeptical. In 2004, the Bush administration issued an executive order calling for a universal “interoperable health information” infrastructure and electronic health records for all Americans within 10 years.

And yet, in 2011, only a fraction of doctors use electronic patient records.

In an effort to change that, the Obama economic stimulus plan promised $27 billion in subsidies for health IT, including payments to doctors of $44,000 to $64,000 over five years if only they would use EHRs. The health IT industry has gathered at this multibillion-dollar trough, but it hasn’t had much more luck getting physicians to change their ways.

What is wrong with doctors that they cannot be persuaded to adopt these wondrous information systems? Everybody knows, after all, that the Internet and mobile apps, powered by Microsoft, Google, and Apple and spread by Facebook, Twitter, YouTube, and the iPhone and iPod, will improve care and cut costs by connecting everybody in real time and empowering health-care consumers.

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The Wonks Are Wrong

I’ve heard critics express the idea a thousand times in a thousand ways.

The idea goes like this:

The system is terrible. It is fragmented. It is inefficient. It is too costly. It relies too much on specialists. Patients with chronic disease see too many over-paid specialists who don’t talk to each other. What we need is more well-paid primary care practitioners. They will provide accessible, continuous, comprehensive, coordinated, connected-electronically, and patient-centered rather than specialist-centered, care.

The Shadow

The problem is between the idea and reality falls a shadow. Patients aren’t listening.

They prefer the choice and freedom of picking their own doctor. In many cases, this doctor is a specialist who treats their specific problem. Patients feel they have enough information to make their own decisions as to what physician to choose. The American public is specialist-oriented. This is why the typical Medicare patient with chronic disease sees 5 or 6 specialists a year, rather than going through a personal primary care doctor who directs their over-all care

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Of Zebras, Rare Diseases, and Google

When you hear hoof beats behind you, don’t expect to see a zebra.

Medical aphorism on the rarity of rare diseases

A rare or “orphan” disease affects fewer than 200,000 people in the United States. There are more than 6,000 rare disorders that, taken together, affect approximately 25 million Americans.

National Organization for Rare Disorders (NORD)

I have been asked to speak before a group of seniors about rare diseases. The thought fills me with trepidation. I am not an expert on rare diseases. There are so many of them. I fear being misquoted or misunderstood. I worry about malpractice implications, even though I am no longer in practice.

Nevertheless I am going to give the seniors my two cents worth, which is about what my opinion is worth. The temptation is irresistible. “To talk of diseases,” as Sir William Osler said, “is a sort of Arabian Nights entertainment.”Continue reading…

Primary Care Revolt: Replace the RUC

An under-the-radar revolution is going on out there. It is a revolt of primary care physicians against the AMA and CMS. It is a request for parity with specialists. It is a movement to replace how primary care practitioners are paid.

Why the revolt against the AMA and CMS? Because primary care doctors yearn to correct myths about primary care vis-à-vis specialists, and because they believe, by altering how the AMA and CMS pay doctors, health costs can be brought down, and primary care can be re-invigorated. Health systems with a broad primary care base have lower costs. In the U.S., two-thirds of doctors are specialists, and one-third are in primary care, the reverse of most nations, which have 50% or lower costs.

In the early 1990s, the AMA formed the Relative Value Scale Update Committee (RUC), which specialists now dominate. RUC sets payment codes for doctors. Since RUC’s inception, the payment differential has been growing between primary care doctors and specialists, so much so that the typical primary care doctor now makes only 30% of what an orthopedic surgeon makes. On average, primary care incomes are 50% of those of specialists.Continue reading…

Computers in 2020

It is 2020.   Computer evaluation of patients before they visit their doctors has come a long way.

Medical records containing  demographic  data,   personal histories,  medication use,  allergies, laboratory results,  radiologic images,  electrocardiograms, rhythm strips, and even the chief complaint and symptoms of the patient ‘s  present illness, as spoken and digitized by the patient,  are available prior to the visit.

These records, synthesized, summarized,  algorithmized,  and otherwise massaged by massive computer banks,  give doctors everything they want to know before seeing ore examining the patient.

  • the differential diagnosis,
  • the most likely cause of the visit,
  • optimal treatment options,
  • a review of recent medical literature in the last 24 hours on the subject,
  • the best current medical practices,
  • the best value for the dollars in the immediate region and at national centers,
  • the best, most cost-effective and results-effective,  specialists  and medical centers  where  to go should further evaluation be needed.
  • the tests and procedures to be done before the patient leaves the office.

This barrage of information is available to consumers and physicians alike before and immediately after the visit.   Furthermore,  with advances in speech recognition,  patients and doctors will be able to talk to the computer in each other’s presence, ask questions, and settle any lingering doubt.Continue reading…

Ba-Ba-Ba-Ba Boom!

January 1, 2011 -Yes, yes, it’s true. Today 79 million baby boomers, born from 1946 to 1964, start turning 65.

Yes, yes, it’s true. Boomers begin qualifying for Medicare.

Yes, yes, it’s true. If my math is right, this means some 12,015 boomers each day over the next 18 years will enter the Medicare ranks.

That’s the biggest news this New Year’s Day. The second biggest news is the information technology boom, triggered by IPad, Kindle, and the social media. The third biggest news, connected to the first two, is the health reform law and its impact on our unsustainable entitlement programs.

Let’s take these pieces of news, one by one.


Boomers, whether by Botox, cosmetic surgery, exercise, antioxidants, tobacco cessation, or life-style and life-savings medical technologies, plan to maintain their youth, and to cede nothing to generations that precede or follow them. That’s if things do well. Otherwise, aging boomers who become ill, may ask , “Why me? What the hell happened?”

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Value (Outcomes/Cost)–A Unifying Concept for Health Reform?

In health care, stakeholders have myriad, often conflicting goals, access to services, profitability, high quality, cost containment, safety, convenience, patient-centeredness, and satisfaction.

-Michael Porter PhD, Professor, Harvard Business School

Those who support the new health reform law and those who seek to repeal it look at the new law through vastly different ideological lenses. Each ideological camp has its own implacable, rarely movable spin on what’s important.

But, according to Thomas Lee, MD, associate editor of the New England Journal of Medicine and networks president for Partners Healthcare System in Boston, the search for value (outcomes relative to cost) unites and provides a path forward for competing ideological interests.

In Lee’s words, “The value framework offers a unifying framework for provider organizations that might otherwise be paralyzed by constituents’ fighting for bigger pieces of a shrinking pie (“Putting the Value Framework to Work,” New England Journal of Medicine, and December 23, 2010).

As an ideological and idealistic concept, I would like to think a utopian vision focusing on value is achievable. But I remain dubious because of the nature of American culture. I am also skeptical partly because the concept originates in Boston, which has the highest health costs in the nation but which has scanty evidence that its outcomes are superior. Finally, I am leery because it takes large organizations with interoperable and expensive electronic systems that communicate with each other to measure value (outcomes/costs) for a bewildering number of different diseases with different outcome dimensions (survival, degrees of health recovery, time to return to work, side effects, pain, complications, adverse effects, sustainability, long term consequences) all measured over a longitudinal time frame among diverse stakeholders. Bringing such scattered data points into a single focus with a common understanding among diverse participants over a long time frame strikes me as nearly impossible.

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