Joel Diamond 5/20/09

What’s Wrong with ICD

I suppose only geeky doctors amuse themselves like this: my medical partner and I used our EMR messaging to send ICD-9 related insults to each other throughout the day.

For instance, I pointed out that his E828.9 (accident involving animal being ridden) was undoubtedly due to his 302.1 (zoophilia arotica). This was after he accused me of frequent CPT 54450 (foreskin manipulation). Clearly this was one of the most flagrant examples of religiously-inaccurate coding, by the way. Besides, I told him that he should be so lucky with his 752.65 (hidden penis). All this led to a serious E960.0 (unarmed brawl).

Why is ICD-9 so rich in its expression of seemingly silly/worthless diagnoses, but falls so short in reflecting the realities and nuances of day-to-day medical care? No doubt, that it has been widely used as a tool for billing. I suppose that someone finds the need to accurately code for E928.4 (accident due to constriction by hair), and am fascinated by the ability to drill down to great detail, such as E910.2 (water activity injury without diving board). Much has already been written about the need to document E845.9 (spacecraft injuring another person).

What about the heralded switch to ICD-10? I’m not sure how the 318 codes for diabetes mellitus are going to be helpful, but I an so glad to know that there will be V32.22  (Occupant of three-wheeled motor vehicle injured in collision with two- or three-wheeled motor vehicle, person on outside of vehicle, nontraffic accident, while working for income).

Like many physicians, I didn’t worry too much about this before EMR adoption. I admit that I would scribble a single diagnosis on my superbill and let my billing staff “do the rest”. When I first used an EMR, I was shocked to find out that I needed to specify an ICD-9 code in order to complete my documentation. One of my earliest frustrations with adoption was the difficulty in finding the code that I needed. Fibromyalgia could only be documented as “myalgia and myositis unspecified” (729.1). I had to search for a long time to find a code for hemochromatosis—finally deciding it was 275.0, (disease of iron metabolism).

Despite the “geekiness”, controlled medical vocabularies and semantics will have to be tailored to the needs of “real” doctors as we move forward with HIT adoption.

In the meantime, I hope that you don’t get E905.4 today (bitten by a venomous centipede) or know anybody with the misfortune of a 929.0 or 937.0 (look them up yourself!)

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 5/19/09

Specialists in the Phoenix area will soon be able to provide consultations via videoconferencing. St. Joseph’s Hospital and Medical Center is implementing Clinical InfoNET technology to enable specialists at the hospital to connect with referring doctors in the community.

The ONC releases its timetable to address the HITECH portion of the ARRA. Missing: details related to the “meaningful use” definition. Instead, the report says, “specific understanding of what constitutes meaningful use will be determined through a process that will include broad stakeholder input and discussion. HHS is developing milestones for major phases of the program’s activities with planned delivery dates.” Translation: we haven’t figured out what we are doing yet and aren’t ready to commit to anything. The good news is that we can expect a few more weeks of opinions from every “expert”.

Children’s Medical Center in Dallas has become the first hospital to tweet in real time during a transplant surgery. Can someone explain the value of this? Wouldn’t watching it and/or reading a summarized transcript be a better use of time?

Physicians spend an average of three hours a week interacting with health insurance plans, according to a study sponsored by The Commonwealth Fund and the RWJ Foundation. Nurses spend 23 weeks a year per doctor and clerical staff spend 44 weeks a year per doctor. Estimated total national cost: between $23 billion and $31 billion a year, which is six times more than the federal government spends on the SCHIP program. A second study found that clinicians spend an average of 35 minutes a day on billing and insurance-related tasks. After adding the cost of administrative staff to perform billing functions, the annual cost for these activities is over $85,000 per physician, or 10% of revenue.

Healthcare attorneys warn doctors not to automatically delete e-mails from patients, but instead archive them to maintain a complete medical record. In fact, using e-mail for doctor/patient communication should be a business decision that weighs the financial and liability risks and benefits. Opinions vary, but some attorneys recommend saving all patient-related e-mail in case it includes any personal health information that should be protected under HIPAA. Those lawyers always want to make everything so complicated.

A Virginia internal medicine doctor leaves her busy group practice to start her own “no-insurance” practice. Dr. Brenda Arnett only accepts cash or credit cards, leaving patients to file their own claims. She bills by the hour and because she is receiving payment up-front, she finds she can afford to provide each patient individualized attention. She also makes house calls (taking along her laptop).

Chicago-area physicians are finding their patient volumes are increasing as a result of extending office hours. For example, the outpatient clinics at Loyola University Medical Center (IL) now stay open later and many are opened Saturdays. After the first month, clinic visits grew 11%, compared to no growth in patient volume for several previous months. Retailers figured out a long time ago that if you made your services available during traditional non-working hours, you could attract more customers. The question now is whether physicians will continue to offer more patient-friendly hours once the economy rebounds.

Ecliplisys’ PeakPractice solution is now a conditionally CCHIT Certified 08 Ambulatory EHR product. PeakPractice is still pending completion of the advanced ePrescribing requirements.

RelayHealth’s Pharmacy Solutions Group is providing the CDC with antiviral prescription data to help monitor the spread of the H1N1 virus with tracking maps and infection timelines.

Last week we mentioned the thousands of patient charts found in a dumpster in Texas. This week’s chart dumping story takes place at a Tennessee recycling center, where thousands of patient charts were discovered, complete with Social Security numbers, personal health information, and before and after photos from a plastic surgery office. Does this happen out of ignorance, stupidity, or laziness?

E-mail Inga.

Intelligent Healthcare Information Integration 5/16/09

Ray Says, “It’s Not My Fault”

During my weekly channeling session with our local psychic (Palm Reading – $5.00), we received a surprise visit from none other than Mr. Big Mac himself, Ray Kroc. He had one main message that he asked me to pass along: “It’s not my fault.”

Curious as to the origin of his defensiveness, I prodded him for elaboration. Paraphrased here, Ray said, “The whole freakin’ world [he used ‘freakin’ a lot] has gone mad. Everyone wants what they want at the exact moment they want it. ‘News’ is now obtained in sound bites and 140-character ‘Tweets.’ Entertainment is always two ‘clicks’ away. Social skills are nurtured without any face-to-face society. Dinner is drive-thru or RadarRange [sic] ready. OK, maybe I did contribute to that last one, but, the point is, I’m freakin’ sick of everybody saying the current excessively fast-paced and shallow civilization is ‘a McDonalds World.’”

Curious, too, as to why he broke in on my séance with the good Doctor Theodor Geisel, I asked for a bit more. He said, “Healthcare is the last great bastion of common sense. Where else can you see such tremendous amounts of time and money spent on providing longwinded and often redundant information? Only healthcare, with its vast reach into every corner of humanity can possibly stop this freakin’ onslaught of the digitization demons. Only healthcare can restore sanity to a too fast world. I need you doctors to spread the word so people will stop blaming me and start remembering what it’s like to actually go slow, to experience deeper thoughts, to wait for what you want.”

Freakin’ honored by his mission bestowment, I couldn’t help feeling, though, somehow partly responsible for the problems Ray worried over. I have an EHR, and a smart phone, and a DVR, and a microwave, and have even digitized my children. I have used many a drive-thru and I’m LinkedIn and Facebooked and Twittered. I, too, can barely read emails past the “two sentence rule”.

But, as Ray spoke (through Madam Blavatsky,) I began to see his point. Healthcare, with its typical foresight, was actually the best place to restore some sanity to our too-fast-paced world. Where else, except maybe newspapers, do you see centuries-old technology still the primary tool? Ink and paper continue to rule the vast majority of healthcare and, with relatively minor exceptions, have shown the true value of grindingly slow communications, agonizing wait times, and almost limitless redundancy of information. If we get on it now, before this mad rush to techno-health really takes hold, we in healthcare services could actually stop the insanity and help restore Ray’s good name.

So, Mr. Kroc, here’s my first salvo for you: Healthcare peeps, let’s slow this world down. As leaders in this return to common sense, let’s keep our repetitive forms and impossibly illegible paper charts (and, of course, 3 X 5 cards.) Let’s sign off of Sermo, leave LinkedIn, face only real books, and Tweet ta-ta to technomania. EHRs? Forget ‘em. As vanguards of health, we medical folks need to stand firm in our resolve to turn back this maddening rush life has become and keep our noses firmly buried up our Luddistic derrieres.

Thanks, Ray.

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.

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News 5/14/09

From Dr. Lyle: “Re: Meaningfuluse.org.  I am assume you saw this. There may not be two more important words in the English language right now. How they are defined will affect if/how EMRs are fully adopted and whether they are used in a way that truly makes a difference… In other words, the very fate of our healthcare system may rely on how this is defined in the weeks and months ahead.” Dr.Lyle is referring to the recent announcement from Compuware and the Association of Medical Directors of Information Systems about their new www.meaningfuluse.org website. They claim it provides HIT with a “single, central location” to discuss the definition of meaningful use. Dr.Lyle is correct: this definition is everything, which is why we are seeing a flood of opinions from vendors, professional associations, and other stakeholders. We’re weary of all the posturing and are ready to hear the definition.

The University of Minnesota Physicians (UMP) group selects MedAptus’ Practice Plus Edition for charge capture automation. UMP expects to complete the MedAptus rollout to its 700 physicians by the end of the year.

At a recent Digital Healthcare Conference, Marshfield Clinic (WI) CIO and physician Robert Carlson indicated that after three years on EMR, his clinic is moving its focus beyond the input of clinical information and more to the use of data to better manage patient health and outcomes. Administrators are also trying to make sure the use of technology does not hinder their doctors’ abilities to be doctors, especially after receiving a patient e-mail telling one doctor, “You make a better data clerk than a doctor.”

It’s one of a practice’s biggest fears: what if the computer goes down while patients are still being seen? At Mashburn Medical Center, a computer virus forces administrators to close its four community health centers earlier than usual Tuesday to give IT staff time to resolve a spyware problem. IT staffers at the North Carolina facility were installing a new computerized pharmacy system when the computer began crashing, affecting data for the health centers. Rather than risk damage to patient information, the system was shut down. Fortunately it was back up in time for patients the next day and officials are confident no patient data was compromised.

EMR vendor Nightingale announces its position as Canada’s most widely accepted Web-based EMR, serving over 200 healthcare providers. The company also has a number of US clients using its PM and EMR solutions.

Will this model catch on with physicians? Startup company Physician Capital Group (PCG) allows doctors to input billing information via a Blackberry or iPhone immediately after seeing a patient. The data is downloaded to PCG’s computers, which automatically determine the doctor’s compensation from the insurance company. Within hours, PCG mails the doctor a check for that amount, less its 12% commission. PCG deals with all the insurance collection issues. Assuming the average billing service charges 6% of collections, will doctors find that getting paid a bit faster is worth another 6%, especially when the providers are essentially entering the charges themselves? And how much faster is it to get a check mailed to you the same day/next day versus receiving electronic remittance directly to your bank account?

Internet-based EMR/PMS provider Waiting Room Solutions announces that Genesis Health Clinic (IA) is installing its solution. Can’t say we know much about this company, though its site indicates it is 2006 CCHIT certified and its hosted solution runs $600 per month per physician, plus set-up.

In this age of HIPAA, paper shredders, and privacy advocates, how exactly does this happen? Dozens of boxes with thousands of patients’ personal information and medical histories are found in a recycling bin outside of a Goodwill store in Texas. Police men resorted to dumpster diving to retrieve the records.

What should come first: EHR or interoperability? In an article published in the Atlanta Journal-Constitution, the IT manager for a major global distribution network argues that EHR is the wrong prescription for healthcare automation.The better approach is to develop seamless connections or interchanges that enable patient data exchange. Much like a travel agent or travel site can “talk” to various airlines, rental car companies, and hotels to create a single travel record, an interchange would allow connection between disparate systems and even create a patient record as a bi-product. Which raises the next question: who pays for it?

E-mail Inga.

News 5/12/09

Providers and patients now have a web site to monitor healthcare safety issues in real time. The FDA launches its new Sentinel Initiative web site that will electronically link data from multiple sources about medication and other FDA-approved products. Users can also sign up for email updates.

A Harvard medical professor co-authors a study on EMR adoption in Massachusetts in 2005 and 2007 and determines that adoption rates jumped from 23 to 35% of practices. There was little change, however, in the use of system features thought to increase patient safety and efficiency, such as reminders for tests.

A former cardiologist pleads guilty to Medicaid fraud and agrees to repay the government more than $1.1 million. Dr. Fabian Aurignac admits he employed unlicensed foreign doctors, billed for consults that never occurred, and offered patients Wal-Mart gift certificates for agreeing to undergo unnecessary procedures. The current charges come a year after the state medical board suspended his license to practice. Once without a license, Dr. Aurignac began to see patients out of an RV parked at flea markets and adult day cares, sometimes bribing the day care operators to gain access to residents.

More doctors, including specialists, are giving up their independent practices to become hospital employees. Financial concerns tend to be the driving force, especially when doctors are compare the costs to purchase costly EMRs versus using a hospital-supplied system.

Here’s proof that physician resistance to technology is not unique to the US. In Japan, an estimated nine percent of physicians claim they would close down their practices rather than adopt online medical billing. Cost is a major concern.

Live in Boston? Then expect wait 63 days to see a family practice physician and up to 70 days to see an OB/GYN. These figures represent the longest average doctor appointment wait time, according to a national survey. Far better to get sick in Miami, when it takes only a week to get in to a family practice office, though a cardiologist could take 29 days. Across five different specialties analyzed in 15 metropolitan areas, the best results were found in Atlanta with an overall average wait time of 11 days. These figures come courtesy of the 2009 Physician Wait Time Survey. Incidentally, the wait times were comparable those found in a similar 2004 study.

This new health care plan sounds a bit like a Sam’s Club for medical care. A group of Detroit-area physicians introduce monthly fee discount cards that offer patients savings on many routine medical services. For $25 to $65 a month, patients are eligible for 40-60% discounts on routine office visits, lab tests, X-rays, EKGs and other non-hospital treatments.

A NY physician, concerned by the number of patients losing their jobs and health insurance, begins offering patients a flat $79 a month fee that covers unlimited preventive visits and onsite medical services such as minor surgery, physical therapy, lab work, and gynecological care. State insurance officials notify him his model is not legal and for sick visits he must charge enough to cover his overhead, which he estimates to be $33. The state insurance officials claim the rules are meant to protect consumers. Hmm … sounds perhaps like the officials are trying to protect the insurance companies, but what do we know?

The Seton Family of Hospitals Community Health Centers (TX) selects billing service provider AMPM to manage its revenue cycle for clinic services.

Despite tough economic times, concierge medical practices are not seeing much decline in business.

The slower economy is blamed for a 12% decrease in cosmetic procedures last year. One plastic surgeon says the business for such procedures for breast augmentation and face lifts has been “flat”. Seems like a curious word to use when discussing breast augmentation surgery.

iMedica appoints Dr. Raymond J. Rabius to its board of directors. Rabius is a strategic advisor to the president of Walgreens’ Health & Wellness Division.

Health insurer Highmark announces it will contribute $1 million to provide training and support doctors who adopt EHRs. The company is paying up to 75% of the cost to buy, install, and implement an EHR.

E-mail Inga.