News 3/3/09

Kansas Governor Kathleen Sebelius (at right in the picture) is picked by President Obama to be the secretary of Department of Health and Human Services. Her primary healthcare experience was an eight-year stint as her state’s insurance commissioner. If confirmed, Sebelius will oversee the Office of the National Coordinator of HIT and CMS.

President Obama also names former Clinton administration veteran Nancy-Ann DeParle (in the center of the picture) as Director of the White House Office for Health Reform, the "health czar" position conceived by Obama’s original HHS secretary nominee Tom Daschle. DeParle managed Medicare and Medicaid in the Clinton administration and ran Tennessee’s Department of Human Services from 1987 to 1989. She sits on the board of Cerner, Medco Health, and Boston Scientific, which could raise concerns about conflicts of interest. Cerner’s report indicated that she made $195,000 from the company in 2007 (cash and stock) and held around $1 million worth of its stock at today’s price.

The New York Times provides an update on NYC’s Primary Care Information Project, a $27 million endeavor started two years ago. To date, over 1,000 physicians are live on eClinicalWorks, which is now installed in two hospital outpatient clinics, 10 community health centers, 150 small group physician offices, and one women’s jail.

Navicure announces (warning: PDF) its new self-service patient kiosk solution, Navicure Check-In, which can operate stand-alone or be integrated with a practice management or HIS. The kiosk facilitates insurance verification, including real-time information on co-pay’s and deductibles.

The day before the annual meeting of the American Academy of Orthopaedic Surgeons, physicians, nurses, vendors, and other volunteers built a playground in North Las Vegas. The 6,000 square foot playground is designed to be fully accessible to children with physical disabilities.

We are proud to announce the sponsors of HIStalk Practice, all of which officially came on board March 1. Our Founding Sponsors are EHR Scope/EMRConsultant and RelayHealth. dbMotion is a Platinum Sponsor and Hayes Management Consulting is a Gold Sponsor. We’ve known all of these companies for some time through HIStalk and we cannot thank them enough for their help in bringing you HIStalk Practice (we’re amateurs working day jobs in healthcare IT, so the support of those companies means a lot to us). Please give their ads a click and check out their offerings if you are so inclined.

A retired Virginia physician recalls his early days in practice in the late 1950s, in which an office visit cost $3 and a house call $5. The average wage was $1 an hour and 80% of patients paid. Today’s average hourly wage is $18.50, but I’d venture to say the average office visit is not $55.50. 

However, for $1.99, you can now load a iPhone application that will help you diagnose your symptoms and figure out just how sick you are. Self Care Decisions just introduced SymptomMD, giving users the ability to use one device to talk on the phone, check email, and figure out the cause of that nasty rash.

Speaking of RelayHealth, we interviewed SVP Jim Bodenbender on HIStech Report.

The eight-physician Cary Orthopaedic Sports Medicine & Spine Specialists (NC) claims it has eliminated transcription costs and paper charts since implementing ChartLogic EHR in 2006. 

This may be an early warning sign of ARRA’s industry impact: KIG Healthcare Solutions (EMR reseller) and Precision Practice Management (medical billing) get a mention in the St. Louis business paper for strong growth. KIG expects to double its staff in the next 18 months. We interviewed KIG’s Scott Anderson not long ago.

An increase in newly built medical office space and the weaker economy may work to the advantage of physicians. An excess of medical office space is providing physicians with options to move into new and larger space or renegotiate rates on current leases. Or, perhaps buy your own building at a lower price if you are so inclined.

Massachusetts gets kudos for its healthcare reform and is often promoted as a model suitable for national rollout, but the Boston Globe says its program flunks all five criteria advanced by IOM: universal coverage, not tied to a job, affordable to those covered, affordable to society, and providing access to care for everyone. Its respective arguments: over 200,000 residents still don’t have coverage, insurance is still tied to jobs, even marginal coverage is expensive that starts at over $800 per month including premiums and payments, state costs have doubled to $1.3 billion, and high deductibles and co-pays prevent insured patients from seeking care.

Blue Cross Blue Shield gets $10 per claim for processing North Carolina’s state employee medical insurance claims, 18 times what the state pays for processing Medicaid claims. The extra $20 million being paid to BCBS wasn’t noticed until lawmakers met to consider bailing out the state health plan, which will go broke this month and needs $250 million to run through June. BCBS claims its margin on processing claims is 0.625%.

The business section of the New York Times features an article called How to Make Electronic Medical Records a Reality, with the answer apparently being regional health I.T. extension centers as recommended by Blackford Middleton and use in the New York City’s Primary Care Information Project. The leader of that group, an assistant city commissioner in the health department, said, "There’s no way small practices can effectively implement electronic health records on their own. This is not the iPhone."

If you’d like a house call, you may have to pay $1,500 a year, plus a per visit fee, if you are a patient of Dr. Natalie Hodge. She claims that technology has made house calls easy, saying all she carries is her iPhone, laptop, and a high-tech cooling system for medicine.

It seems like just yesterday that we launched HIStalkPractice, but actually it’s been almost two months. So far we have had over 14,000 visitors and our subscriber base grows daily. If you have not signed up for updates, you can use the handy box on the top right of the page. We appreciate feedback, so if there is anything you think we could be doing differently, send us a note.

Internal documents released Friday indicate that AstraZeneca suppressed unfavorable studies on its multi-billion dollar psychiatric drug Seroquel. An e-mail from a company official praised its project physician for minimizing negative findings, saying, "Lisa has done a great ‘smoke-and-mirrors job!" In another, the company’s publications manager indicated that three sets of drug trials had been "buried."

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Intelligent Healthcare Information Integration 3/2/09

U.S. Healthcare Overhaul? Sure … in 5 Easy Steps!

The unfettered free market system has done about as well for Healthcare as it did for its cousin, Finance. I personally believe in capitalism, but perhaps guided capitalism is necessary when universal concerns are involved (to corral the misguided – right, Mr. Madoff?) It appears to me that without some form of nationalized healthcare supervision (the dreaded ‘socialized’ medicine monster?) it is unclear if we will ever stop digging deeper this healthcare hole. Exactly what form of federal regulation and to what extent we need it is controversial, but I do know we must address the problem, preferably with some new, creative thought.

With this in mind, my dear Mr. Obama, et al, I here offer up the …

“Official Grunt-in-the-Trenches Complete U.S. Healthcare System Overhaul and National Health Information Network in Five Easy Steps Disruptive Innovation Package”

…for your review and consideration.

As this is a blog spot and not my personal manifesto home page (now there’s an idea!) I will offer the steps to Healthcare Nirvana as a serial blog, limiting each rant …er, discussion …to one of the component steps.

STEP ONE

Living Your Name – What to do with HMOs, MCOs, & Inscos

Health Maintenance Organizations – HMOs, Managed Care Organizations – MCOs, and Health Insurance Companies: read the names and forget your now ingrained biases. Don’t the names themselves actually imply something pretty desirable? Isn’t the goal of U.S. healthcare overhaul as a whole, and the National Health Information Network as a subunit thereof, actually seeking to provide better healthcare maintenance and management for the every U.S. citizen, both those who can and those who cannot afford it?

Unfortunately, such organizations have evolved (devolved?) into entities less concerned with helping maintain and manage quality care services than they are about maintaining and managing profit margins and bottom lines. With constant focus on cost containment, earnings, and shareholder happiness, how can we expect them to have much room left for actual patient care concerns? (Personally, I generally avoid talking about providing healthcare to patients as all patients are people and “they is us.” Somehow, categorizing people as patients adds a degree of distancing I find distasteful).

Health insurance companies are, at least, less evasive about their agendas; they are about money, period.

It is a fact that HMOs, MCOs, and health insurance companies are a gigantic part of our current economic system, not just healthcare. When considering our currently distressed jobs and economic picture as a whole, they are important and integral considerations. The entire economic structure is in need of a major tune up and, most talking heads agree, an “overhaul” of the current U.S. healthcare quagmire is crucial to the success of our recovery. I suggest an adjustment in our thinking might provide us some helpful wrenches for the servicing we need on them all.

Problem One: Corporate profits, not people’s health, have become preeminent

As we are seeking to improve the healthcare and the efficiency of its provision for all Americans, let’s prioritize that as “Job One”. Yes, we are a capitalistic society and I, for one, have no desire to see healthcare socialized. But, to achieve the better “bang for the buck” that we all know we need here, I propose that the goal of quality care for all Americans be kept preeminently in view and all other considerations become subservient to that goal. Thus, I propose a redefining of the term “health maintenance organization,” a redirection of healthcare’s middlemen, and a retraining of their workforce to maintain (or even create) jobs and begin improving the efficiency of healthcare provision using current tools. (Not to worry; geeky techno-tools will be promoted soon!)

Answer One: Live Your Name

As both a “grunt in the trenches” solo physician and as one of the American people who has health that needs care, I would love to have the assistance of a health maintenance organization to help me manage the overwhelming information and requirements modern healthcare entails. If my health info was better organized, shared, and managed, I have no doubt I could better help both the people I treat and myself.

Current competing and conflicting procedure approvals, payment choices, formulary differences, and other issues separating the major middlemen corporations only serve to confuse, complicate and “chaotisize” healthcare…not to mention the effect upon accelerating costs.

Suppose there was one acceptable formulary structure, that quality measures could be promoted universally, that health maintenance care was paid better than (or, at least as well as) health repair, that our struggles with healthcare provision were about improving “best practices” not “best reimbursements.”

How about retraining many of those current so-called “HMO” (or other middlemen) employees – and their bosses! – to help guide and support quality healthcare decisions? If they weren’t spending their time fighting for profits, we could use them to actually help “health maintenance” such as:

1. Helping people with

a. Appointment reminders
b. Test and procedure prompts
c. Vaccinations schedules
d. Finding appropriate services

2. Helping providers with

a. Information organization
b. Credentialing
c. Group pricing and supplies tracking
d. Care plans and protocols
e. Patient compliance support

3. Helping researchers and epidemiologists with

a. Data tracking and coalescence
b. Disease monitoring
c. Large prospective studies
d. Best practices design and follow-up

With a uniform set of payment and approval guidelines, most of the people who now spend their time “delaying, denying, and defending” in order to enhance healthcare’s middlemen profits could begin to “unite, support, and assimilate” (USA!) healthcare information to enhance actual healthcare provision. We can’t afford to simply eliminate these giant middlemen of medicine, even if their amazing corporate headquarters of marble and mahogany spit in the face of their initial role to curtail healthcare costs. We need their workforce and brainpower, just redirected towards actually helping healthcare instead of sucking off its marrow.

Health maintenance organizations, managed care organizations, and health insurance providers – helping doctors provide care, not dictating care provision, and, actually living up to their names. Scandaleux, oui?

Still to come:

Step 2: Two Thirds of the NHIN by 2010

Step 3: Equalizing the Playing Field (“Open” is not a Four Letter Word)

Step 4: EHR? PHR? Phooey! How About an IHR

Step 5: Verdant Health

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.

Intelligent Healthcare Information Integration 2/28/09

Chumming the Sharks

Did you happen to catch the Mythbusters episode where, off the coast of South Africa, they chummed a feeding ground for sharks at breakfast to see if a dolphin could deter these ravenous beasts from chowing on a helpless little seal? (Don’t fret, PETA people, both the seal and dolphin were man-made). The fake seal was always chomped within seconds without its mammalian mate, but whenever it was in the water nearby, the incredibly real-looking robo-dolphin was 100% effective keeping the sharks at bay.

Well, I waste your time discussing a TV show because I see an ominous analogy.

As you well know, Obama has now set his signature to the Grand Economic Stimulus Package promising over $19 billion to healthcare info tech (not to mention the 100-some billion for CMS, et al.) Even before the pen hit the paper, you could see the HIT waters churning with the frenzied maneuverings of all the “sharks” scurrying to see their version of healthcare digitization fed. Since the signing, the “seas” have been virtually bubbling with their voracious intrigues. (Imagine what’s happening behind the scenes if we can see this much commotion above the surface!)

Me? I feel like one of thousands of helpless little seals swimming along, looking for my buddy Flipper to keep my fur firmly affixed to my hide. The giants of this sea – big centers, big RHIOs, big HIEs, big insurance, big EHR/technology vendors, and big governmental groups – are all thrashing about, stirred by the perceived problem-solving chum of the Obama bucks.

Here I sit, in my little town, in our little community hospital, knowing full well that virtually all of the solutions the sharks are promoting are oriented toward the big boys in the big cities in the big centers. All the while, they ignore that nearly 70% of the NHIN will be comprised of small communities, their associated small hospitals, and their affiliated docs. We, the seals of the US healthcare information technology world, desperately need a dolphin to help us avoid becoming the aftertaste of the sharks.

Maybe Barry (did you know Barack was called ‘Barry’ in college?) and company could be our dolphin. We don’t need all the HIT bells and whistles the sharks are selling, just a little seal’s basic model. A truly end user-oriented, patient-centric, but community-driven solution — a little “HIT Mini Cooper,”  if you will — for the MAJORITY of us, instead of one of those sharky Rolls-Royce or Humvee HIE/RHIO/CHIN thingies.

I have a plan for such a system which, for a relatively small chunk of the Stimulus Stash, we could implement for some 70% of the country and …

Aw, crap…did I just sprout big teeth and a dorsal fin?

Dr. Gregg Alexander is a grunt-in-the-trenches physician and admitted geek. He runs an innovative, high-tech, rural pediatric practice in London, OH, and can be reached at doc@madisonpediatric.com.

News 02/26/09

Availity and Humana offer free electronic prescribing systems to San Antonio, TX physicians. Eligible physicians will be provided a portable handheld device that is custom-installed and configured to work with their practice’s patient scheduling system.

Fort Worth, TX-based HIE Sandlot goes live. Healthvision provides the backbone technology and is integrated with EMRs from Allscripts and NextGen. Sandlot is a subsidiary of the 600-member North Texas Physicians IPA.

Multi-speciality groups are on the rise as doctors try to achieve economies of scale as reimbursements fall and overhead increases. ProHealth (NY) is the featured example of this trend in a local business journal. ProHealth has doubled in size over the last two years and now includes 14 locations and 150 physicians.

Uncle Sam will pick up half the cost the country’s healthcare spending by 2018, according to CMS.

Device manufacturer Medtronic will disclose payments it makes to any physician that exceed $5,000, starting next January.

Always on the lookout to help sell the wares of its vendor members, HIMSS rolls out its Online Buyer’s Guide. The vendor ads are flanked by HIMSS ads on the individual pages, setting what seems like a record for commercial pitching for a non-profit.

Three healthcare organizations representing over 1,150 physicians select Medical Present Value to provide real-time patient eligibility verification. The new clients include the 1,030- provider Medical College of Wisconsin, which is directly integrating MPV with its GE Centricity PM product.

The former patients of a Colorado family physician ask state and local authorities for help getting their medical records after the doctor moves out of state and leaves them behind.

EMR vendor AllMeds announces a 27% increase in 2008 revenues compared to 2007.

CCHIT adds three new products to its list of 20 Certified ’08 Ambulatory products: MedicsDocAssist by Advanced Data Systems, SILK, and e-MDs.

A survey confirms what most physicians already know: Americans are skimping on healthcare because of cost concerns. Fifty-three percent of the 1,500 people surveyed relied on home remedies, skipped dental care, postponed medical care, or did not filled prescriptions in order to same money. Nineteen percent said that medical costs were causing severe financial hardships and one-third fear losing their healthcare coverage.

The AAFP and the American Academy of Home Care Physicians (AAHCP) lobby CMS to correct an oversight in the e-prescribing incentive program. As currently written, the law precludes house call physicians from participating in the e-Rx incentive program. The program does not not include the CPT codes used by house call physicians and CMS claims that changes won’t be made until at least 2010.

A new study finds that 44% of patients who received reminders for screening tests are compliant versus 38% of patients not receiving a reminder. The use of electronic alerts within an EHR improved screening rates only if a patient visited the physician three or more times.

A Chicago pediatrician reportedly freaks out during her Medicaid fraud trial, first being forcibly removed from the courtroom after ranting in court about the stupidity of the judge and her own attorneys, taking evidence from her attorney’s office, then screaming "Lock me up" at the judge from behind the glass partition where the judge had ordered her to be moved. She then refused to turn over evidence files she took and took off without returning, now the subject of an arrest warrant (all alleged, of course). Here’s her blog, which features an impressive educational background and a bizarre career history. Bet you don’t see this on a CV very often: "Recruited staff for and coordinated development of new county hospital pediatric department – Provident Hospital of Cook County [where Dr Shelton witnessed patronage hiring fraud and corruption – by Cook County Board President John Stroger Sr’s godson Orlando Jones who he appointed the CEO – Mr. Jones committed suicide after he was indicted by the US Attorney in Fall 2007]" There are two sides to every story, of course.

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Joel Diamond 2/25/09

I love the HIStalk entries describing "odd lawsuits". Unfortunately, these seem to be an increasing norm in the business of healthcare. Those of us who practice on the front lines often feel that we have a malpractice target painted on our backs. It always amazes me how public policy experts downplay the huge financial burden of defensive medicine.

A few years ago, while covering for another physician, I was asked to see a young woman in the hospital who had been admitted for chest pain. She was scheduled for some diagnostic testing before I ever met her. During one of her tests, a small piece of equipment came loose and touched her chest, causing no harm. I was contacted and made arrangements for incident reports, investigation into procedures, and additional X-rays to rule out injury. 

After all this was completed, I visited the patient and met her for the first time. I apologized for what happened and assured her that I would personally follow up on the incident report that was filed. She responded to me, "No need to worry, Doctor, ’cause as soon as I leave here, I’m going straight to my lawyer". 

I told her that I was disappointed to hear that since she had no physical or psychological harm, and that additionally, I would most likely be named in any lawsuit as well. She then proceeded to tell me that I shouldn’t care. "That’s why you have insurance," she stated. After assuring that she was healthy, I turned to her as I exited the room and told her to "have a nice life".  

Sure enough, a few weeks later, I was served court papers. Amongst other grievances, I was accused of "insulting" her. Needless to say, the case was eventually dismissed, but not after lengthy hours taken away from patient care, replying to investigations, and attending depositions. 

When the case settled, I asked my attorney if I could actually pay a few hundred dollars to the plaintiff out of my own pocket in return for a half hour of her time. "Are you insane?" he asked. "Why would you do that?" I replied that I just wanted an opportunity to demonstrate for 30 minutes what an insult actually was.

I am frequently asked if I think that EMRs will have an effect on malpractice. In the situation described above, clearly not. There is no doubt, however, that improved documentation along with detailed access to patient data will be impactful. If we can figure out how to properly invoke clinical decision support, we can further mitigate risk. 

On the other hand, bad doctors will always find ways to exploit the EMR and use it for inappropriate short-cuts in both care and documentation. I have no doubt that there is a growing cottage industry of attorneys looking to exploit this technology in creative new ways to sue doctors. I shudder to think of what will certainly be a future accusation, "Just because you clicked an option that said ‘all normal’ does not mean that you actually performed a thorough exam." This is why I urge all physicians using an EMR to use extreme caution when documenting by exclusion.

Ending odd lawsuits is not something I can control, but improving the delivery of care to my patients is.

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.