Joel Diamond 6/2/09

Controlled Medical Vocabularies

In my last post, I discussed how our current coding systems just don’t suit the needs of everyday working physicians. For some reason, it got me all nostalgic for the good old days of paper records. Nothing like curling up in front of the fireplace with an old novel. Ahh … the texture, the smell …

OK, the reality of paper charts: falling apart, disorganized, and an odor best characterized by the last body orifice examined.

My EMR records are so much more complete and accurate, yet I will admit that there are subtleties that are often lost. For instance, my long-since retired, older partner was fond of writing F.I on the front of certain patients’ charts. This was to boldly remind him that a patient was a “(expletive deleted) idiot”. I remember when I first went into practice, one of his patients was staring at the outside of her chart while I was talking. “Dr. Diamond”, she asked, “what does F.I. mean on my chart?” Thinking quickly, I blurted out that my aging partner liked to label only the charts of his favorite patients, designating them as “fine individuals”.

Then there are the long-lost abbreviations written in the margins of countless charts — meant to convey a certain nuance that is sadly missed in today’s templated notes. Most of us fondly remember the sign-off on complicated VA patients: AMF YOYO— an encouraging “adios, mother (expletive), you’re on your own”. The essence of a patient’s condition could often be wrapped in the gallows humor of a cryptic abbreviation: ART (assuming room temperature), FTD (fixing to die), or an order for PBAB (pine box at bedside).

The term SWAG written next to a differential diagnosis conveyed to the reader that this was just a “scientific, wild-ass guess”. The conclusion to a discharge summary, TTGA (told to go away) somehow told the real story. An opening description such as LOLINAD (little old lady in no acute distress) will be missed as much as the politically incorrect description of the pediatric patient’s parent, GLM (good-looking mom).

Don’t get me wrong, I strongly advocate the use of CMT (controlled medical vocabularies). Codifying information in reproducible terminology is necessary for a true longitudinal record, which can be used for analytics and research and effectively allows communication amongst the health care team.

It’s just that some days, I miss chuckling as I enter the exam room — wondering how I’d explain my old partner’s unabashed label of his opinionated and misinformed patient as ABITHAD (another blithering idiot, thinks he’s a doctor).

Joel Diamond, MD is chief medical officer at dbMotion, adjunct associate professor at the Department of Biomedical Informatics at the University of Pittsburgh, and a practicing physician at UPMC and of the Handelsman Family Practice in Pittsburgh, PA. He also blogs on interoperability.

News 6/2/09

From Deborah Peel “Re: security. Today’s interconnectivity can also put patient data in jeopardy. It’s time for all physicians — not just plastic surgeons — to wake up to the risks of using HIT systems without ironclad security or consumer control over data use. The national professional organizations for medicine and nursing are AWOL on the key policy issue of putting their patients first by restoring the Hippocratic Oath and privacy rights in electronic health systems.” The privacy rights advocate is referring to this article published in the Cosmetic Surgery Times, which stresses the need for physicians to safeguard their healthcare IT systems against patient privacy breaches. The article quotes an attorney who says, “The cost of civil penalties or remediation resulting from a data breach may add up to significant dollars, but the more significant loss is the loss of public trust.”

QSI, the parent company of NextGen Healthcare Information Systems, reports flat net income for its fourth quarter ending March 31. Revenues rose 29% to $65.8 million. The company said results were affected by delays in purchasing decisions related to ARRA uncertainties.

The Texas legislature hopes to attract more physicians to underserved rural areas of the state with the passage of new medical school loan repayment bill. bill. If signed by the governor, it will set up a fund to repay up to $160,000 in student loans for any medical school graduate who agrees to practice in one of the rural counties of Texas for at least four years. The funding will come from a new tax on smokeless tobacco products.

Meanwhile, the American College of Physicians and others are lobbying Congress to provide scholarships and loan repayments for students pursuing careers in primary care specialties. The Preserving Patient Access to Primary Care Act is designed to address critical shortages in primary care providers.

Maryland becomes the first state to enact legislation requiring private insurers to offer financial incentives to health care providers for adopting EHR. The same legislation requires the establishment of a statewide HIE.

The 20-provider Horizon Eye Care (NC) selects SRS ePrescribing and OpenPath technology for its seven-office practice.

Check out our new “Industry Events” link in the green column to your right. Click to view the HIStalk calendar that is designed to keep track of industry activities. Readers can submit their own events (subject to approval). The calendar includes links some cool features, including maps and current weather. You can even download an event to your calendar.

Also on HIStalk: to date, 91% of HIStalk readers responded “no” to the question, “Is CCHIT free of HIMSS influence?”

A physician from the Bronx who received free EMR software through NYC’s Primary Care Information Project claims the move to EMR was “one of the best decisions” he ever made. Dr. Sumir Sahgal see improvements in his practice, particularly in the monitoring of medications for elderly patients. Sahgal was one of 200 doctors serving underprivileged communities who benefited from the Primary Care Information Project. Though the software was free, Sahgal and his four partners spent over $40,000 in out-of-pocket costs plus the cost of PCs.

Tenet Healthcare announces the creation of MED3OOO Practice Resources, a joint venture with MED3OOO that will focus on providing services to physician offices. Tenet, which has a 20% stake in MED3OOO, will offer services to physicians in the 12 states in which Tenet operates. MED3OOO Practice Resources will provide HIT and management services to participating physicians, which will include most of Tenet’s employed physicians.

Though many “house-call” doctors are slammed for being available only to the wealthy elite, here is one doctor that seems to break the mold –- on several levels. Dr. Dale Hamrick didn’t decide to become a physician until age 39. In reading the article in the local Charleston, NC paper, it sounds like most of his income is from Medicare and he does not charge any type of membership fee to be part of his practice. Because he covers a wide geographic area, he only sees 10 patients some days. He carries a laptop (presumably for chart notes) and is currently looking at voice recognition software to save time. How can you not like a doctor who wears jeans and works out of a pickup?

Natalie Hodge is a pediatrician offering a more traditional house call, concierge-style practice that relies heavily on technology, including a pediatric web portal, secure electronic medical records, podcasts, and iPhones. In fact, the Personal Pediatrics practice website touts its use of “21st century technology.” Hodge claims her “old model” office-based practice used to cost $200K a year to run, versus $50K with the new model, with both providing the same revenue.

If you are an employer who prefers your employees work even when they are sick, you might want to check out Medicine At Work, which provides physician services in the workplace using telemedicine technology. The physician connects remotely while a local paramedic assists with the exam on site with the patient.

Leonard M. Fuld, the head of competitive-intelligence firm Fuld & Company, predicts that Obama’s planned acceleration of EHR adoption will drive consolidation in HIT and threaten many small physician practices. Fuld predicts that “hundreds of thousands” of small practice doctors could be forced to join larger groups, largely due to the expense and complexity of adopting EHRs.

Practicing physician William Carlson is named chief medical officer and director of PHR vendor Connectyx Technologies holdings Group. Carlson is an orthopedic surgeon with a practice in Florida and also serves as president of the medical staff at Martin Memorial Health Systems.

Humana beats out Aetna and Cigna in athenahealth’s fourth annual Payerview Rankings. The rankings examine which insurers are paying the fastest. The overall survey results indicate that the insurers are paying physicians 5.3% faster and denying 9% fewer claims than last year.

HealthLINC, an HIE based in Southern Indiana, is awarded federal funds to implement Axolotl’s e-prescribing technology for Bloomington-area physicians and pharmacies.

E-mail Inga.

News 5/28/09

If Massachusetts lawmakers have their way, “sorry” will no longer be the hardest word for doctors to say. The state is considering a bill that would let doctors say “I’m sorry” without admitting they made a medical mistake. Expressions of condolences or compassion would be inadmissible as evidence should a medical malpractice lawsuit be filed.

Southwest General Health Center (OH) selects Allscripts Professional EHR for its 30 employed physicians. The practice will deploy the EHR via the Software as a Service model and integrate the Allscripts application with its existing MicroMd practice management system.

divx twilight

Retail clinics in grocery stores and retail chain stores seem to be following the money, with most setting up in regions with higher median incomes and lower poverty rates. No surprise that Wal-Mart, CVS, and others prefer areas that offer better odds of getting paid.

We’ve recently mentioned incidents involving paper medical records showing up in dumpsters and recycling centers. Now a Michigan doctor is being made to pay $350,000 to settle a lawsuit with the Michigan Department of Health, which charged the doctor of improperly disposing medical records from a now-defunct hospital. The doctor burned the charts at his farm, which frankly sounds like a far better solution than the dumpster and recycling options. I suppose in all these cases people are trying to save a few bucks by not hiring a professional contractor to get rid of the charts. Hasn’t anyone ever heard of a paper shredder?

EMR/PM vendor gloStream secures $7.5 million in series B financing to bolster its development, marketing, and sales efforts. gloStream plans to hire additional staff across the company to further develop and promotes its Microsoft Office-embedded EMR and PM solutions.

The Richmond Academy of Medicine (VA) aligns with NextGen reseller TSI Healthcare to offer Academy members preferred pricing on EHR and billing services. The Academy is an alliance of 1,700 doctors in the greater Richmond area.

Medical billing companies PracticeMax and MedaPhase merge to form one of the largest regional billing service companies in the southwest. The new entity, PracticeMax, will focus primarily on revenue cycle management needs of ER and urgent care physicians, along with certain other specialties.

The gloves come off in the continuing debate of the role of HIMSS and CCHIT in HITECH payments. The Washington Post ran two semi-critical articles suggesting that HIMSS used its lobbying influence to convince the Obama administration to spend billions on healthcare IT, then pushed CCHIT (which it was involved in creating) as the certifying agency for EHR products. In an apparently unplanned third article, the Post ran some heated comments from CCHIT head Mark Leavitt in response to these comments from Dr. David Kibbe: “One has to question whether or not a vendor-founded, -funded and -driven organization should have the exclusive right to determine what software will be bought by federal taxpayer dollars…It’s important that the people who determine how this money is spent are disinterested and unbiased…Even the appearance of a conflict of interest could poison the whole process.” Leavitt’s response: “For months, I’ve been ‘turning the other cheek’ to Dr. David Kibbe … his repeated use of falsehoods and innuendo to attack CCHIT have found an audience in the national media, reaching a level that can no longer be ignored. By implication, he demeans the integrity of everyone who has contributed to that work – and I must rise to their defense.” More of Leavitt’s comments are in the graphic above.

Allscripts CEO Glen Tullman earns a “Best of Illinois” award from the Juvenile Diabetes Research Foundation Illinois chapter. Tullman, whose son and niece have Type 1 diabetes, was recognized for his service on the Illinois Board of Directors, on the International Board, and for his support of the organization’s efforts in developing an artificial pancreas. Glenn’s brother Howard wrote about the event and took the picture above, which I found on his site.

Memorial Health University Physicians (GA) selects McKesson’s Revenue Management Solutions for billing and practice management. The group will deploy McKesson Practice Complete, which includes the Horizon Practice Plus financial application and RelayHealth Ambulatory Claims Manager.

About 150 Alabama physicians are pilot testing a new e-prescribing tool made available from the state’s Medicaid agency. The e-Rx technology is part of QTool, a web-based EHR and clinical support tool developed by ACS to support Alabama Medicaid’s statewide EHR system.

Here is an interesting article, geared to the average consumer, that explains some of the key benefits of EHR. The stuff mentioned sounds great: fewer trips to the doctor’s office because EHRs allow you to converse with your doctor online; personal access to your medical records online, regardless of where you are in the world; and no more dragging X-rays (or another diagnostic test results) from doctor to doctor because everyone can see them online. Maybe the average consumer wants to believe all that, especially since their tax dollars are going to subsidize the purchase of EHRs. The rest of us are left wondering how long will it take to achieve nirvana.

Properly implemented HIT, including EMRs and electronic prescribing, is a requirement for changing the model for primary care that is in place today. So concludes a New England Healthcare Institute report that claims HIT improvements would increase physician time during visits, provide timely access to information, and aid in the overall coordination of care. The study calls for a number of additional innovations to improve the quality of primary care, including patient-centered medical homes and better pay-for-performance initiatives.

E-mail Inga.

Intelligent Healthcare Information Integration 5/27/09

Life in a Little Trench, or Supply Side HIT
atb – two worlds cd1 download
A “grunt in the trenches.” That’s a term I’ve used to describe who, what, and where I and thousands of healthcare providers like me are, occupationally speaking. It is probably a different perspective than many you’ll see on these pages. Please allow me a moment to offer a few descriptive moments to sketch out that picture a bit more.

• I’m a solo pediatrician in a small town (pop. ~9,500) in the rural flatlands of central Ohio.
• I’m on call for neonatal emergencies and C-sections 24/7/365.
• I love living in and serving my small community. I’m the medical director for the county health department, a member of the town planning commission, a local United Way board member, a Rotarian, a member of the local hospital Foundation Board, and have a spot on our town’s Bicentennial planning group.
• In the last three years, my true “vacations” have totaled 3 days.
• Our busy little practice serves a rural populace: about 65% of our families are Medicaid.
• I locally host our EHR on two servers. For IT for our office, I’m it.
• My three wonderful employees started off almost fully computer-illiterate. (OK, one knew how to turn a computer on, one didn’t, and one called the mouse a “duck.” Seriously.)
• I spent hours upon hours researching more than 200 EHRs, demoed scores of systems, and went into deep detail on the finalists before deciding upon an EHR for our office
• Life in my trench includes traffic “jams” of six cars and friends who know me before I’ve ever seen them. It allows for a trip to the post office, a bank deposit, picking up a prescription from the pharmacy, grabbing a forgotten paper from my home, and being back to the office, literally, in less than twenty minutes. There are Scout meetings, sports, school functions, and homework. I insist upon family time and some (admittedly brief) down time.
• I don’t miss big city life in the least.

I’m not offering this description to glorify myself nor anything I do. Rather, I am a very run-of-the-mill, small community, primary care physician. There are thousands more like me out there, working hard to care for our communities and families. We have wonderful, fulfilling lives and enjoy our labors.

There is, however, something missing from our great little lives. We need inclusion in this great big HIT discussion going on. With very few exceptions, nobody’s talking about us – even though we serve the majority of US healthcare needs. Systems and plans are almost completely focused upon the Mayos, the Clinics, the HIEs centered around giant centers, etc. Doesn’t anyone care about all us little grunts out in the frontline trenches?

It seems most everyone’s focused on the big guys and their bigger pools of money. Even the purported Keynesian liberals in political power now seem to be counting on the “Trickle Down Effect” (or its precursor, the “Horse and Sparrow Theory” from the 1890s) to spread HIT from the big centers to all us little guys. Last time it was the conservatives telling us grunts how well we’d all be served by supplying the big boys’ side and letting us little fellows feed off the crumbs that fell.

OK, so that was finance, not healthcare IT. I suppose it’ll work better this time.

Dr. Gregg Alexander is a grunt-in-the-trenches pediatrician and geek. His personal manifesto home page…er..blog…yeh, that’s it, his blog – and he – can be reached through http://madisonpediatric.com or doc@madisonpediatric.com.

News 5/26/09

A California eye surgeon uses Twitter to provide patients’ friends and families with surgery updates. His staff has set up a Mac notebook in the waiting room and he Twitters his patients’ status to a private Twitter account at the conclusion of a procedure. The 42-year-old doctor says that using Twitter is “just a different way to do outreach.”

A Florida ophthalmologist hopes the economic stimulus package will boosts the growth of his sideline EMR business. Dr. James Croley designed Quickview Medical Records, which is targeted for use by ophthalmologists and optometrists. Currently the product is being marketed across 20 states and costs about $14,000 for a typical office.

The Arkansas physician injured in a February 4th bombing hopes to return to his family practice in July. Dr. Trent Pierce, who is also chair of the state medical board, lost his left eye and hearing in his left ear after an explosive device went off in his driveway. No one has been charged with the incident, though officials say they have a person of interest.

AAFP subsidiary TransforMED signs a strategic partnership with EthosPartners to provide a customized analytics tool to integrate and track operational and financial performance in primary care practices. TransforMED’s client base will have the opportunity to use Ethos’ VitalStats to track RCM, physician productivity, and other practice measures.

Transcription service provider MxSecure plans to incorporate M*Modal’s Conversational Documentation Services and speech recognition into its MxTranscribe EHR document management software.

Physicians for uninsured African-American and uninsured/Medicaid Latino patients are less likely to use and EHR than physicians primarily treating privately insured white patients. In general, physicians in urban areas and in group practices utilize EHRs more than doctors in rural areas and solo practices. This article does not theorize why, but likely the cost of technology is the primary factor.

The sluggish economy is making physicians less likely to leave an existing practice, based on findings from an AMGA survey. Last year physician turnover was 6.1%, compared to 6.7% in 2006. In addition, 62% of physicians are delaying retirement due to economic conditions. In other words, physicians have found their 401Ks shrinking, just like the rest of us.

Montana physician Dr. Ron Bearss gives up his private practice for three months to care for soldiers in the Middle East. We thank you for your service.

E-mail Inga.