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.

E-mail Inga.
E-mail Mr. HIStalk.

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.

News 2/24/09

From Nomer Stimpson: "Re: stimulus and for-profits. Why is Micky Tripathi getting recognition for anything at this point?  The Mass eHealth Collaborative is a bust, New York treats him like he’s a god, and in the end, he’s just Girish Kumar’s cousin (by marriage, I believe) pushing eClinicalWorks." I asked eCW President Girish Kumar Navani and here is his response: "Thanks for asking the question, your desire for getting the facts is one of the big reasons HIStalk continues to grow. No, Micky is not related to me or anyone at eCW. He is not my cousin. During the MAeHC project, eCW did a very good job implementing practices. We completed the EMR deployments earlier than the planned milestones. We also deployed the Health Exchange software ( eEHX) on time and we came in line with our costs and completed the project on time and budget. I can’t speak for anyone else, but generally speaking, people do tend to comment positively for others when dealt with fairly. I will not be surprised if you start to hear the same from NYC-PCIP project, eCW has successfully implemented 1100+ providers in NYC with 99%+ adoption of the EMR; I guess we are probably related to them as well."

Speaking of eCW, Girish believes the federal stimulus package will allow his company to add 500 jobs within two years. That is pretty aggressive growth considering the company employs 750 today.

McKesson announces its Achieve IT Web site and telephone center for doctors interested in learning more about the impact of the economic stimulus plan.

Clarkstown Medical Associates (NY) rolls out mPro Care, the first two-way mobile diabetes solution that provides automated reminders and accepts readings via standard cell phone.

CCHIT will launch nine new certification programs: clinical research, dermatology, advanced interoperability, and advance quality (all of which are new), plus planned newcomers for behavioral health, long term care, eye care, oncology, advanced security, and advanced clinical decision support. OB/GYN has been tabled until 2012. If you believe certification protects physicians from bad products and sticks to its original purpose of guaranteeing interoperability, then you will probably like these (other than their cost if you’re a vendor). If you didn’t like CCHIT in the first place, they’re giving you more reasons to congratulate yourself for seeing this coming.

A transcription company lapse is blamed when patient records from Northeast Orthopaedics (NY), including full dictations and patient data, are found to be openly accessible on the Internet.

Pulmonary Associates claims its $260,000 EMR investment reduced transcription costs by $53,000 and allowed them to hire four more doctors without having to add more clerical staff. Pulmonary Associates is a 13-physician, two-office practice in Delaware.

Physicians who prescribe electronically through the Rochester RHIO are now able to view the medications prescribed by all providers. Axolotl’s Elysium Exchange and EMR Lite software facilitate the this data exchange, which also includes lab results, radiology reports, and medication history.

President Obama appoints Mary Wakefield head of the Health Resources and Services Administration. Wakefield, a nurse at the University of North Dakota and head of the university’s Center for Rural Health, will lead the agency as it distributes $2.5 billion from the economic stimulus bill. The agency is a division of HHS and responsible for improving access to healthcare services for the uninsured and improving health care in rural communities.

Visions@Work announces the launch of its Preferr product to help physicians automate the referral process. The product will be available on a monthly subscription basis and includes patient data exchange, referral tracking, and secure provider-to-provider communications.

Now that the leaders of the Medical Records Institute have left to lead the non-profit mHealth Initiative, the obvious question is: what will happen to the annual TEPR conference?  Does the industry really need another conference? Let us know what you think. 

Noteworthy Medical receives a "substantial" equity investment from German ehealth service provider CompuGroup. Hard to believe it’s been a year since Noteworthy acquired practice management vendor MARS Medical Systems.

After its deal with Health Systems Solutions falls apart, imaging vendor Emageon agrees to sell itself to AMICAS. Just a couple of weeks ago, Emageon was to be acquired by HSS for $62 million, but last-minute financing issues caused the deal to fall through. Even though the AMICAS deal is $23 million less, Emageon is ready to become an AMICAS subsidiary.

Pee Dee Cardiology, a 16-provider group in SC, selects EHR and PM products from Allscripts to replace its Misys system originally purchased in 1987.

Antek HealthWare releases a practice management system for concierge practices, stripping out the billing capability and instead simply printing an invoice for the patient to pay (bet everybody wishes payment was that simple in their practice).

Mt. Carmel Health System (OH) will cut a number of patient programs as well as its physician practice management service.

A liberal think tank says four million Americans have lost their health insurance since the recession started (it seems like such a quaint time last fall when economists argued whether it was really a recession, technically speaking).

A California woman pleads guilty to running an unnecessary surgery scam, recruiting phony patients for an outpatient surgery center by offering cash or free plastic surgery. It was not a small operation: the fraud covered 45 states and $154 million.

A nurse suing Flushing Hospital (NY) for allowing a doctor with a history of sexual harassment to proposition and grope her and other nurses for eight years is awarded $15 million, with the doctor and hospital splitting the tab. It’s the largest award to an individual in a sexual harassment case in state history.

E-mail Inga.
E-mail Mr. HIStalk.