News 6/11/09

From Skeptic: “Re: industry growth. We’ve been hearing the pundits predict 20-30% annual growth for the last 10 years. As of the end of last year, only 4% of physicians were using a fully functioning EMR. So maybe vendors are selling more and the market is ‘growing,’ but I am waiting for proof that physicians actually have the real tools they need to reach an adoption tipping point.” Meaningful use, perhaps?

From iPhone fan: “Re: upgrade to the 3GS. You said you just upgraded to the 3G model. Apple has a 30-day return policy so you should just take it back and get the new one.” I spent 20 minutes today holding on the phone to speak to someone at Apple about my options and finally hung up. Guess I am going to have to drag myself over the Apple store and ask one of the geniuses there. Meanwhile, other iPhone users are angrily blasting Apple about the unfair upgrade pricing.

Dr. Chris Rangel, who blogs at www.RangelMD.com, details an EMR disaster story that resulted in the loss of several months worth of medical records. The short version is his three-doctor practice bought an EMR and an in-house server. The selected EMR “looked good on the outside but was a pile of feces on the inside.” Training was inadequate and IT support was incompetent. Ultimately the practice lost data because the backup was set up incorrectly. Dr. Rangel is now using an on-line EMR, which he thinks is the way to go if you are in a small or medium sized practice. He suggests that the main reason some doctors “set up complex in-office software and hardware configurations” is because they want want maintain control. Says Rangel: “Having a stand alone system will make as much sense as building a minipower plant in your back yard to provide your home with electricity instead of taking it off the grid.” His piece is humorous, in a tragic sort of way. However, I think he falls short with his recommendation that using a Web-based solution is the automatic answer. Software can be “a pile of feces” whether it is an in-house or on-line solution. Both type vendors may provide poor training and support. Regardless of the infrastructure, make sure you do plenty of due diligence, including talking to current and former clients.

Peter Orszag, director of the Office of Management and Budget, shows strong support for HIT at a conference earlier this week. Orszag stresses the need for more information tied to medical systems so that doctors and hospitals know what works and whether additional procedures are warranted. He believes IT is a requirement for delivering the necessary data.

iMedica’s EMR/PM solution wins an endorsement from the Physicians’ Organization of the University Medical Center at Princeton, a PPO with 500+ physician members.

A former hospital employee is sentenced to a year in prison for her unauthorized access of the medical records of an AIDS patient who was feuding with one of the woman’s friends. She posted the information on her MySpace page. The woman was only 20 at the time, but it’s a pretty sad to think how many stupid (and mean) people are running around in this world.

Vermont strengthens its already tough stance on gifts to doctors from pharma and medical device firms. No more free lunches, as all meals and travel expenses are banned. Gifts to prescribers are no longer allowed and any payments to doctors – regardless of the amount – must be reported to the state.

The Southern California Orthopedic Institute selects SRS EMR for its 51 providers.

Former Eclipsys CFO Bob Colletti is named CFO for e-learning vendor Learn.com.

New Jersey-area HIT vendors claim EMR interest is surging. Businesses anticipate a positive economic impact by the end of the year as ARRA reimbursement details are finalized.

Another Kaiser Permanente employee (a nurse) is accused of wrongfully peeking into the medical records of her son’s second grade teacher. The nurse claimed the teacher said something derogatory to her son, her husband sent a letter to the school board claiming she was unfit to teach, and (according to a tipster) the nurse then pried into the teacher’s medical records. The teacher is suing the nurse and Kaiser, charging conspiracy, negligence, invasion of privacy, and emotional distress.

The use of electronic clipboards at the Iowa Clinic has reduced patient check-in time from nine to three minutes, according to the practice’s CEO. Patients update their information using a stylus and computer screen rather than a pen and paper. Administrators at the 140-physician practice also believe the new process has resulted in more complete patient data, especially insurance detail. Each tablet costs about $3,000.

E-mail Inga.

News 6/9/09

On the rise: the number of immediate-care clinics. The trade group Convenient Care Association estimates that 1,200 such facilities are now operational across the country. This is in addition to clinics located in retail pharmacies. Meanwhile, many of the drugstore health clinics are expanding services to include injections, care for strains, and treating chronic conditions such as asthma and osteoporosis. Physician groups continue to voice skepticism.

The VA announces plans to allow researchers to use de-identified, aggregated data of veterans to pinpoint the most effective treatments for specific conditions, including post-traumatic stress disorder and antibiotic-resistant staph infection.

This study estimates that the 2008 market for EMR data transfer equipment and applications was $575 million, but will reach $1.6 billion in 2013. That’s over 23% a year growth.

Genesis Physicians Group (TX) signs an agreement with revelationMD to provide clinical integration to its 1,460 member physicians. Genesis will invest over $100,000 to implement the exchange technology. Between 60% and 70% of the providers will be able to access the service for free, while others will pay between $100 and $200 a year.

Last week we mentioned the medical billing specialist/community college medical billing teacher who was arrested for allegedly bilking her employer out of $157,000. Now a second practice has come forward and claims the biller, Catherine Yount, stole nearly $54,000. In both cases, Yount is accused of depositing insurance company payments into her account, rather than her doctors’.

Center Pointe Sleep Associates selects the ZMR software from SleepEx for its EMR and sleep lab management system. I had never heard of SleepEx, but it claims its Web-based EMR and lab management solutions are the most widely used by sleep diagnostic and therapy providers, installed in over 150 locations.

Apple announces its new iPhone 3GS, which includes some spiffy new enhancements over the previous 3G version. Now available: a digital compass, video, and voice control, plus a more speed and a longer battery life. The $199 price tag is the same as the 3G had been (although reading the fine print, I think the $199 price is only for brand new AT&T clients — existing clients will pay $499 for the same phone, which hardly sounds fair.) Meanwhile, the 3G version (which I upgraded to just TWO weeks ago) just fell in price from $199 to $99. Apple also released details of its new 3.0 software for the iPhone. Cut and paste, a landscape-mode keyboard, and improved search capabilities are some of the nicer enhancements. The update is available June 17th and free for iPhone users. Finally, Apple notes there are now over 50,000 applications available on the iPhone, with medical applications the fastest growing category. Likely the biggest barrier to widespread clinical adoption will be the iPhone’s limited battery life.

Claims clearinghouse MD On-Line acquires competitor Medical Claim Corp.

Most healthcare providers believe ARRA funds earmarked for HIT will have little or no success in encouraging EHR adoption. Sixty-six percent think EMRs could positively affect their bottom line and 75% believe EMRs could positively impact healthcare as a whole. Most also believe P4P could lead to improved patient outcomes, but 79% fear the increased reporting and record-keeping would increase the costs of doing business. Budget concerns continue to be the biggest barrier to adoption.

RelayHealth wins Target Corporation’s 2008 Partner Award of Excellence for demonstrating “innovative leadership, superior business practices and commitment” to Target’s core strategies. The award was presented at the recent National Council on Prescription Drug Program’s annual conference.

A New York doctor claims that his use of technology and streamlined processes has enabled him to offer more personalized care to fewer patients while maintaining the same income level. Dr. José Batlle uses online appointment scheduling, EMR, electronic prescribing, and virtual visits by phone and e-mail. He says he spent about $25,000 to buy the technology and estimates it saves him close to $100,000 a year in salaries and billing costs.

Alta Bates Medical Group (CA), a 600-physician IPA, agrees to settle FTC charges that it violated anti-trust laws by fixing prices charged to health care insurers. Alta Bates agrees not to collectively negotiate fee-for-service reimbursements and engaging in similar anti-competitive conduct.

This Boston Globe article points out the potential inaccuracies of online doctor rating services, such as Angie’s List, RATESMDS.Com and DR.SCORE.COM. Over 40 different sites now allow patients to rate their doctors, but ratings and the posters cannot always be verified. While some doctors are irritated or try to game the systems, most seem to recommend the old fashioned way of finding a doctor: asking friends and relatives.

Affinity Medical Group (WI) selects Phytel to identify treatment opportunities and augment its patient-centered medical home initiative. Affinity will first implement Phytel’s Proactive Patient Health Management tools for its primary-care team, before rolling out to all 200+ providers.

E-mail Inga.

Intelligent Healthcare Information Integration 6/8/09

Feeding the Fire of Non-Participation

Amid all of the hubbub around ARRA incentives, federally-mandated disincentives for non-EMR adoption, and best-practices-outcomes-based-evidence-based medical standards with which to comply in order to be ‘allowed’ to be a paid player in healthcare provision, did anyone ever stop to consider the huge – and I mean HUGE – motivational log being thrown onto the fire of non-participation?

I mean, come on, I’m committed to provide the best care possible for my patients. Plus, I’m a techno-geek-gadget-guy from way back. I love and encourage the intersection of healthcare provision and technology. But, when you consider the following, even I have to wonder if the conjuncture of the two worlds might best be promoted outside of the current realm of ONCHIT, CCHIT, and a variety of other ‘chit.’

To wit:

• In order to remain profitable, I participate in around 40 private insurer programs.
• If I generate $4-500,000 yearly, I take home somewhere just into the six figures.
• In order to maintain those numbers, as a primary care pediatrician with a heavy dose of Medicaid patients, I have to see somewhere around 30 patients per day in order to pay my bills and make a decent living. (“Decent living,” by a pediatrician’s standards, as you can see, is not what most specialists would tolerate.)
• If I didn’t have to chart, make phone calls, review labs and other assorted outside medical data, attend hospital meetings, assist my staff, and otherwise run my practice, that would give me 16 minutes face time per patient average in a 40-hour week. (40 hours! Wouldn’t that be nice?)
• I’ll now have to consider 155,000 ICD-10 codes instead of the paltry 17,000 from ICD-9.
• None of this even mentions hospital rounds, emergency C-sections, or 24/7/365 availability.
• I rush through most days and barely know some of my families. (Not to mention my own family.)
• Studies suggest physicians spend at least 1/3 of their time in non-direct patient care work. (I’d suggest that is low-balled.)
• After all of this, in order to “follow my bliss” and pursue technological enhancements of my medical services, I need to detract yet further from my family time, my personal time, or sleep. (Guess which goes first.)

So, follow me here, if I wasn’t a genetic geek, if I didn’t enjoy the thrill of resolving “Blue Screen of Death” issues, if I was like the majority of non-techno-minded primary care docs who lead very similar lives to the list above, how much do you think I would want to add a giant new learning curve into my scheduled chaos? How much do you think I’d want to risk my already meager monies on an electronic health record system that might get reimbursed in a few years?

Now, instead of maintaining 3-4,000 active patients with the life- and work-styles mentioned above, what if I abandoned all of those who can’t pay or who pay poorly and who place excessive non-medically-related demands upon me (both patients and insurers) and switch to an old-timey, doctor-patient-only practice? (Some call the new version, “concierge medicine.”)

I mean, if I didn’t have to answer to insurer and CMS requirements and wasn’t worried about “meaningful use:”

• I would still chart, make phone calls, review labs and other assorted outside medical data, attend hospital meetings, assist my staff, and otherwise run my practice.
• Instead of 30 patients a day, I might see 15 (maybe 5!) – and I would know all of them.
• I could limit my total number of families to a handful of hundreds charging less than $100 per month each.
• Prepayment could include the costs of vaccinations, simple labs, and all office work and procedures, and
• Hell’s bells, I could even do house calls while still more than doubling my take-home pay!

All of this would be allowed without worrying whether or not I have the necessary number of bullet points, if a vision screening or required immunization will get paid or not (or enough), if my receptionist got the co-pay upfront, or if my EMR was being used meaningfully.

Guilt for not helping those less financially endowed? Why? Don’t the families who can pay also have legitimate healthcare needs? Plus, wouldn’t I be actually serving those for whom I work better, with care from a more relaxed, and ergo more focused, medical brain? With the reduced restraints on my time, wouldn’t I have even more ability to help out at the local free clinic or some other philanthropic venture?

Remind me again why I continue to participate with all the restrictions and requirements and rules imposed by sometimes even non-medical people. Jog my memory as to why possible reimbursement of $44-64,000 of my hard-earned moola for the privilege of learning a whole new way to record my work is considered an “incentive.” Tell me once more why participation in a broken medical model, now about to add – oooo, ahhhh! – “Technology,” something often hard to understand and even harder to use, makes sense.

Seriously. Remind me. I think I’m starting to forget as I feel the warm glow from the growing fire of non-participation.

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 6/4/09

While many experts hope that the patient-centered medical home model will solve the primary care physician shortage, Dr. Steven Grant is not as optimistic. He does not believe the proposed pay increases that insurance companies are offering are adequate. Also, the costs of implementing all that is required for a patient medical center home are high – particularly the cost of implementing EHRs.

Children are twice as likely to be underimmunized if parents and children encounter negative vaccination experiences such as poor staff attitudes, long wait times, difficulties making appointments, or feeling their physician didn’t listen to them. To promote compliance, Louisiana’s Medicaid program is now offering additional financial incentives to physicians if at least 90% of their patients younger than 24 months are current on their immunizations.

Allscipts adds SYNNEX as its latest MyWay distributor.

iMedica announces its participation in the American College of Physicians’ EHR Partners Program.The ACP program includes and EHR Comparison Tool, which allows members to review information on 23 CCHIT-certified EHRs and view comparisons of different products.

Medical Network, Inc., a Maine-based independent preferred provider organization, aligns with athenahealth to provide preferred access to athenahealth’s EHR and RCM services. The 4,000 member providers will receive special pricing for athenahealth’s newly CCHIT 2008-certified athenaClinicals and athenaCollector.

Our long-time HIStalk sponsor Vitalize Consulting Solutions is now an HIStalk Practice Gold Sponsor, which we appreciate. They were just named to the Healthcare Informatics Top 100, pretty impressive for a company that’s been around only eight years. They provide consulting services and expert assistance with all the major vendor packages. We interviewed CEO Bruce Cerullo in February – it’s a fun read. Thanks to Vitalize for support HIStalk and HIStalk Practice.

Are you concerned you might have “cell phone elbow’?” Orthopedic specialists are reporting an increase in the number of cases in this syndrome (technically called “cubital tunnel syndrome”) in which patients damage an arm nerve by bending their elbows tightly for too long. The result is tingling or numbness in your pinkie and ring fingers. The prescribed treatment: switch which hand you use to hold the phone.

A Florida medical billing specialist is arrested after being accused of stealing over $157,000 from her pediatrician employer. Her method seems pretty low-tech: she deposited 99 insurance checks into her bank account rather than the doctor’s. The office manager eventually noticed some improprieties and eventually the biller fessed up. Here’s a bit of irony: the accused woman also teaches a medical billing course at the local community college.

Doctors treating patients with multiple chronic conditions will likely be reimbursed fairly under pay-for-performance measures, according to a study by researchers at the Baylor College of Medicine and VA Medical Center in Houston.

Misys PLC moves its executive VP for global sales over to the Allscripts division to serve as chief operating officer. Eileen McPartland takes over for interim COO Lee Shapiro, who will continue his role as President.

If you are attending AHIP Institute 2009 this week in San Diego, be sure to visit HIStalkPractice sponsor RelayHealth. The RelayHealth folks are very supportive of both this blog and HIStalk and even created their own sign announcing their sponsorship. Stop by and tell them thanks for us.

An ER doc who goes by the name of WhiteCoat blogs anonymously  about his recently concluded malpractice trial. Some may question whether it’s ethical to share the details, but so far it’s a compelling read.

Across the country, more doctors are assisting patients with creative payment alternatives, particularly the unemployed and/or uninsured. Pro bono work is up, as are fee discounts and payment plans. A family physician in Florida is allowing chronically ill patients to pay a $75 per month fee that includes a dozen office visits a year plus some lab tests and vaccinations. He established the $75 rate because it was the same amount people spend on their monthly cable bill.

A survey concludes that 33% of all US physician offices don’t accept credit cards for payment, which is 5% higher than last year.  Researchers theorize that fewer doctors are accepting credit cards is because they want to protect their patients from high interest rates. Compared to other specialists, plastic surgeons are much more willing to take credit cards for payment, with 91%  accepting them.

Odd allegations in a Vioxx lawsuit trial in Australia: Merck paid nurses to dig through medical records without doctor approval to find 100 patients who were Vioxx candidates; Merck gave pharmacists copies of the Merck Manual to use as a bribe to convince Tylenol-taking patients into trying Vioxx; and the drug company handed out what looked like an Elsevier peer-reviewed journal called “Australasian Journal of Bone and Joint Medicine” that extolled the benefits of Vioxx, but it was really a phony journal consisting of a collection of favorable reprints.

E-mail Inga.

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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.