An HIT Moment with … Alberto Borges

An HIT Moment with ... is a quick interview with someone we find interesting. Al Borges, MD is an oncologist with Arlington Medical Group of Arlington, VA.

Can EMRs ever be efficient and helpful to doctors when much of what they do is document encounters for payment?

The primary use of an EMR is as a card file or Rolodex to find patients. After that, their use is especially valuable for maintenance of a basic, concise clinical record (including PMH, SH, FH) and then to make great notes (SOAP notes, admission notes, consultation notes).

As you’ve stated, EMR systems are also the basis of most practice management systems (“PMS”) to document an encounter. The use of boilerplate templates is invaluable to make sure that all the necessary items are present for billing the appropriate CPT code level of treatment.

What are some of the other healthcare technology tools you use in your practice, in addition to the EMR?

Google is the first one that comes to mind. I use that for billing (i.e. search for “ICD code melanoma”), for putting together a quick patient handout for an illness, for looking up oncology research protocols, to get medical information (in particular, eMedicine and Medscape are useful sites), for translations (especially English to Spanish), and to get pictures to show patients (Google-> Images).

I also use Dragon Naturally Speaking Standard/Preferred quite a bit. For pulmonary function tests, I use a PC software that works in conjunction with a USB hardware for patients to blow into. (Eventually I’ll also be using a PC EKG, too.) I use MS Access not only for my EMR, but for my practice management system and for chemotherapy. I use MS Works for its calendar feature that can group entries — very helpful for seeing when a particular patient needs more chemotherapy.

The recent proposals in Congress are tying stimulus money the purchase of certified products. Do you think that will eventually mean the end of non-certified products?

No. Check out this quote from a recent CDC report on 10/2007:

“The use of EHR systems in physician offices and medical practices increased significantly in 2006, however, the adoption rate of ‘comprehensive’ EHR systems remained statistically unchanged”

HIMSS may have convinced Congress to go along with CCHIT. What has happened is that they should have tried to convince physicians, who without their participation, CCHIT will not be able to survive. Three facts:

1. Doctors don’t generally want to buy into expensive CCHIT-certified EHRs which offer little to no return on investment.
2. Doctors don’t generally want to use difficult to understand systems that are associated with high failed installation and de-installation rates.
3. Doctors despise the idea of further unfunded mandates and will avoid any products associated with what is perceived to be as political albatrosses that are unneeded and unnecessary.

This is what makes my job as an anti-CCHIT blogger relatively easy — I simply post factual statements aimed at physician potential buyers. HIMSS/EHRVA may have millions of dollars to throw at promoting, lobbying, and advertising for CCHIT, but unless they can win the hearts and minds of end users, they don’t stand a chance at forcing their agenda through successfully.

If you were the government and had visions of a high quality, low cost, interconnected healthcare system, what technology would you recommend or create to meet those goals?

First of all, we have to define “quality”. It used to be based on Board certification, on word-of-mouth by patients who have experienced good outcomes, and on peer review (i.e. physicians send patients to qualified fellow physicians). Occasionally, patients put up with slightly less quality for a better deal (think HMO). Now big government and health insurance companies want to pay as little as possible and to use technology to somehow increase/ensure “quality”.

Now to do this, they have to show studies which have demonstrated quality as well as show that these systems can save money, which neither of which have been proven. On top of that, they want physicians to purchase technology at a very high cost both in terms of money, time, and effort with no expectation of ROI. Now you have President Obama, who wants to force through HIT in less than four years, when this process should go through slow, small steps as the evidence of its value increases.

I feel that big government, if they wish to do anything at all, should focus on the basics, i.e. set up the RHIOs to collect patient data and to provide a way to interconnect computer systems. They should put together an easy way for any EMR to communicate, either through an XML-based CCR record, or through an ODBC-like interface between database systems. The emphasis should be “free” (or very low cost) and “easy”. Let physicians pick the actual low-cost EMR system that best suits their practice patterns and documentation needs, such as keyboarding/boilerplate templates, handwriting recognition, or dictation.

You are a regular contributor to sites like Sermo, EMRupdate, and even HIStalk.  How do you think sites like these and newer social networking sites will impact healthcare over time?

I firmly believe that blog site discussions have had an enormous impact on counter-punching the HIMSS lobbying efforts and will derail any poorly thought out mandates as readers become better informed consumers. I personally have seen a drastic change in the way that e-prescribing, CCHIT certification, and pay-for-performance are viewed in just the past two years. Mention these topics in a positive light in any physician Web site nowadays and you get eaten alive.

In other websites like emrupdate and at HIStalk, where physicians constitute a minority of posters, readers have usually been more open-minded about these things, but even these folks are starting to question the negative impact of these mandates on competition and growth of HIT. Just do a Google search now for “CCHIT” and you will rarely see a positive review outside of the HIMSS Web site.

An HIT Moment with … Bryan Vartabedian

An HIT Moment with … is a quick interview with someone we find interesting. Bryan Vartabedian, MD FAAP is a physician and author of the 33 Charts blog.

Give me some background on yourself.

I am a pediatric gastroenterologist at Texas Children’s Hospital in Houston. I first came to social media in 2006 when I started a blog in order to promote the book I was about to publish. I heard that, as an author, it is really helpful to have a dynamic changing presence on the Internet, like a blog. I started at that time thinking I was just going to use this as a tool to promote my book. I thought I couldn’t keep this up; that it would a few months and die off. But I never really stopped. It kind of evolved beyond just trying to sell a book. I recognized the reach that I had through expressing my opinions on a blog. And so it continued.

It’s really just been over the last month or two that I have transitioned from a blog writing for parents to a blog writing more about issues of health and issues of health and how it intersects with social media. That is a fairly recent development for me even though it has been something I have been actively involved in and interested in. I came to Twitter last year with the same mindset. I said this is kind of interesting. I knew very few physicians on Twitter, said this sounds like fun and jumped into it. I really enjoyed the dialog that I had with other physicians and other patients, it gives me a real lens into what other people are thinking. I have about 1,200 followers currently and I am realizing there is real power to it. I did a post just last night on a new software platform called Hello Health, which is like a Facebook for physicians and allows patients and physicians to interact on a fee-for-service basis. I sent out a Twitter this morning on it and just had an enormous, enormous response. A viral retweeting. There’s no way I could have gotten the word out about that blog post without the assistance of Twitter.

What is your main focus – providing information or health news?

For about 2-1/2 years I was really writing as a pediatrician writing for parents. My audience was really consumer parents looking for information. I was covering timely health issues and parenting and children’s health, providing a unique voice and a real practical point of view for a lot of controversial issues. One thing I realized over time was with parents coming to the web they would come to my site with search engines they’d get information and they’d go away. I found this very unsatisfying because I wanted with my blog a real sense of community, and it’s really hard to develop community around children’s health issues, for whatever reason. Plus, I am a doctor, and it’s parents that are reading. But when I would write about doctor issues, as I am currently, I have a lot more comments and a lot more people who want to chime in and be part of the conversation. I like this idea of generating community around my blog, which was missing in my old way. I used to write health information for parents and now I am doing more commentary on medicine issues and how it intersects with social media.

As social media become a bigger part of healthcare, who stands to gain the most: the physicians or patients?

Interesting because one of the things that I am picking up on (and I am not the first) is that doctors are really late adopters of new technology and social media is a great example of that. There are really very few physicians on Twitter and there are very physicians who blog. If you look at pediatricians who blog, for example, if you scour the Internet you will only find a handful of regularly blogging pediatricians on a consistent basis. Physicians haven’t really taken advantage of using social media, either for themselves or more importantly, to advance health causes.

An example is the issue of vaccines and autism. You hear controversy about connecting vaccines with autism. If you Google it, the first two pages that come up are really occupied with anti-vaccine material. Yet the physicians write very, very little about it. Physicians really haven’t taken enough of a role to generate the content. There are 60,000 pediatricians in AAP, and if each member made one blog post a year on the vaccine controversy, it would dispel all those myths. We’d dominate the search engine with content that is valid.

I really think physicians have an ethical obligation to be part of the blog responses and comments. I don’t think physicians have really taken advantage of it for their businesses or practices or for the promotion or propagation of good health information. I see myself playing a role in trying to explore this space to see how we can use it to our advantage.

Obviously social media use is about helping patients – that’s the obvious sale. And patients are interacting with one another. With Web 1.0 we were really just reading information online, just like you would read a newspaper. But with Web 2.0 we are really establishing communities and communicating amongst ourselves. I have seen this in the office. It has been a huge boon with patients with rare diseases or parents with kids with rare diseases. They have communities and networks where they can share information, and that is really the power there.

Do you think social media are a fad or do you believe it they will eventually become mainstream in their use and acceptance?

I hear that sometimes, that social media is a fad. You often hear it from traditional publicists and traditional public affairs officers who think this is just a passing thing. The idea of people communicating with one another and networking is not a new thing. It’s really just new technology for doing something we have been doing for tens of thousands of year. I don’t think it is going away. The question I always ask is: “How are doctors going to use this? In five years from now, how are doctors going to be using social media?” I can’t answer that question, I don’t know. But I don’t think it is a fad.

How do you get more doctors onto the bandwagon?

There has to be an incentive for doctors to be involved in social media. It’s like adoption of any new technology. There has to be an incentive or a value proposition for them. Someone made a great comment on one of my posts last week about this. Doctors are very, very busy. Until you can demonstrate that being present on Twitter or having a regular blog or being present on the Internet in a social way, until you can prove that has real benefit, a real return on investment, it’s going to be very, very hard to draw physicians into this. It’s happening very slowly. But there has to be an incentive for them. To me it is a no-brainer. My visibility online has yielded all kinds of benefits. But it’s very hard, and we argue about this, how we will get doctors involved in social media.

News 5/7/09

From Marie Curie: “Re: clinical trials. GE with the Centricity Business solution offers an integrated clinical trial and billing management solution called Patient Protocol Manager. This is a new solution and fully integrates the access, billing, and revenue pieces between clinical trial and billing management with Centricity Business (formerly known as IDX). Albert Einstein post refers to the need for a solution.” Thanks. I would be interested to hear from any users actually using clinical trial software solutions.

The executive manager of the Center for Bone and Surgery (FL) details his practice’s transition to an unnamed EHR. Since implementing the EHR three years ago, patient encounters have grown 25% annually, with administrative and clinical costs rising only about 5% a year. The leader of the nine-doctor group also believes the EHR has enhanced their quality of care.

A new report from the office of the HHS Secretary suggests that the 50 million Americans living in rural areas have difficulty accessing healthcare, higher poverty rates, more health problems, and less insurance. Rural communities average 55 primary care physicians per 100,000 people compared to 72 per 100,000 in urban areas. With one in five Americans living in rural areas, the Secretary’s office is calling for comprehensive health reform that addresses these disparities.

An HHS report on National Healthcare Quality paints a pretty dismal picture of the quality of care being provided patients, or, at least the quality of reporting information. For example, 40% of diabetics don’t receive prevention exams and only half of obese patients are given appropriate advice on exercise and healthy eating. The use of HIT and standards-based data may provide better tools to capture data and report on quality measures.

Texas Medical Associations makes EMR selection easier with a new tool designed to help physicians in the selection process. The program provides side-by-side comparison of eight of the top products used by Texas physicians and helps estimate costs.

RelayHealth’s PatientCompass earns the “Peer Reviewed by HFMA” (Healthcare Financial Management Association) designation for the third straight year. To attain the designation, RelayHealth had to undergo an 11-step screening process by a panel of current and potential customers and expert HFMA peer review board members.

The National Institute on Drug Abuse offers a new online screening tool for physicians that will help them assess patients’ tobacco, alcohol, and illicit and non-medical prescription drug use. NIDAMED includes an online screening tool, a clinician resource guide, and a quick reference guide.

There is the medical care that most of us get, then there is the concierge model, and then there is Guardian 24/7. Founded by physicians who formerly served in the White House, Guardian provides “white-glove services” including immediate access to physicians and on-the-spot treatment, fully equipped hospital rooms built into homes and planes, and detailed medical emergency plans for officials, and dignitaries during their travels. The annual rate for most medical service plans is $25,000 a year. “Ready-rooms” for your home (or jet) can run from $175,000 to $1.25 million.

In an attempt to expand its pharmacy market, Wal-Mart begins testing free mail-order delivery of generic prescription drugs. Michigan will be the only state participating initially. Good news for consumers who can now call toll-free numbers to order generic medications for $4 to $10 each.

Sixty-two percent of Michigan physicians say their practices are full or almost full, which is 20% more than claimed the same in 2005.

To help alleviate the growing issue of physician shortages, three Congressmen introduce legislation to increase the number of Medicare-sponsored training positions for medical residents by 15% (about 15,000 slots). In 1997, the Balanced Budget Act froze the number of Medicare-supported resident training slots in hospitals at 1996 levels.

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How does someone fake a complete medical clinic? A Florida man pleads guilty to conspiracy to commit healthcare fraud after officials discovered he had leased space in the name of other medical clinics, opened bank accounts, filed corporate documents, and received Medicare billing numbers. Meanwhile, officials found that the organization had no operations, employees, or equipment. In less than a year, the man filed more than $12 million in Medicare claims and received payment of about $3 million. He is now ordered to pay $3.9 million in restitution and serve four years in prison.

E-mail Inga.

News 5/5/09

From Mr. Cleanjeans: "Re: infection. Next time after a flight, linger to see how well the post-flight clean-up goes. Some airlines (e.g. SWA) pride themselves on everyone pitching in to clean up to turn around the planes faster. What you see sometimes are people with gloves on to protect themselves. What you DON’T see is people with gloves on using antiseptic wipes on the seats, arm rests, tray tables, etc. I put a Purell or similar in the baggie and send it through the scanner!" 

From Albert Einstein: "I have noticed that there is rarely any mention of clinical trials IT vendors on this site. I am not associated with Clinical Trials nor any vendor or consulting group but keep bumping in to the problem of how to manage trials from patient access, revenue cycle and clinical IT integration perspectives. Can we get some help here?" Anyone have any insight on this? We asked Dr. Joel Diamond to share his thoughts on the topic and he replied: "There are some clinical trial vendors—they mostly help with administration of trials. The problem is that the pharma companies still insist on using rooms and rooms full of notebooks and paper to document everything. Some of the companies have some electronic capturing tools for reporting, but they tend to be proprietary for each trial and cumbersome to use. To date, there has been no significant tie-in to EMRs or any kind of standards for reporting and documentation. In my humble opinion, there is an incredible opportunity for EMRs to help with the inclusion and exclusion criteria for selecting patients for trial, and to monitor their follow-up."

The NY City Department of Health and Mental Hygiene wants to integrate a new substance abuse screening tool into the city’s eClinicalWorks EHR program. The interactive program would guide primary care providers through a series of questions and provide a substance abuse involvement score.

Christus Health votes to provide St. Vincent Regional Medical Center and La Familia Medical Center (NM) $300,000 to digitize their medical records.

Doctors’ Administrative Solutions (FL) signs a sales and marketing partnership with iMedica to offer iMedica’s Patient Relationship Manager 2009 and Transition EHR system.

The developers of TurboTax and Quicken introduce Quicken Health Expense Tracker to help consumers monitor their medical bills and payments from insurance companies. The online tool allows patients to view insurance payments and track their portion of medical costs. Wonder if any web-portal companies want to provide any Quicken-ready billing information for patient use?

Allscripts and Edge Health Solutions announce that Edge will offer Allscripts MyWay solution for Mac as part of its portfolio of solutions for Apple hardware.

The owner of a Las Vegas medical spa files a lawsuit against a former employee and her retired cosmetic-surgeon husband after discovering the couple were running an after-hours, cash-only cosmetic procedure business. The former employee used her key to open the spa in the middle of the night and on Sundays. The husband and other plastic surgeons would perform cosmetic procedures that included everything from Botox injections to breast augmentations. The owner claims she knew nothing about the unauthorized after-hours business, which operated for several years and generated as much as $30,000 a night.

Researchers suggest that doctors should spend more time writing and editing Wikipedia on medical topics in order to improve accuracy. Wikipedia has become a major source of health information for consumers, but its editing policy allows anyone to submit or make changes to articles. More physician input could lead to increased credibility of the online encyclopedia.

Practice management billing company TRACT Radiology (OK) selects AMICAS to provide financial software for its billing operations.

McKesson releases its fourth quarter earnings for the period ending March 31, announcing total earnings of $281 million, or $1.01 a share. This is  down from $307 million, or$1.05 a share for the same period last year. The technology solutions segment saw a 2% drop in earnings and flat revenues. McKesson attributes the lower earnings and flat revenues on delayed technology purchases due to the slower economy.

MGMA publishes a list of five reasons why practice administrators should use social networking tools for themselves and their practice. The professional organization recommends the use Twitter, Facebook, and similar tools as a way a free way to gain personal or practice exposure and to help patients find medical information and details on your doctors. Other reasons mentioned include the ability to provide instant communication and to help advance one’s career. Interestingly, the article makes no mention of blogging for social networking.

Readership for HIStalkPractice continues to creep up each month, so thanks for reading. If you haven’t already, take a moment to register for email updates to ensure you never miss a post. And a special thanks for our sponsors who help pay the bills.

E-mail Inga.

Intelligent Healthcare Information Integration 5/4/09

Step 4: Equalizing the Playing Field
(“Open” is not a Four Letter Word; Systems That’d Suit)

If open-sourced crowdsourcing hasn’t shown you its formula is successful, you’re not paying attention. Look at Apache HTTP Server, look at Linux, look at Mozilla Firefox, Java, MySQL, Thunderbird, OpenOffice. Open source and crowdsourcing enhance innovation; support of open source allows profit. Healthcare needs such public/private cooperation to stimulate the innovation necessary for its salvation.

Of the open source EHRs currently available such as OpenEMR, OpenMRS, VistaA & Vista-Office EHR, FreeMed, tkFP, and Care2x, thus far, they are unusable for the masses. Still typically Windows 95-ish, very boxy with lots of columns and rows, their support sites are often heavily laden with tech-head jargon and formatted such that perusing them is laborious. Documentation is usually cumbersome or scanty, often difficult for the lay person to assimilate.

Wouldn’t it be great if a polished, open source EHR could incorporate a “best practices” approach for included elements/design? Everyone’s got their favorites, but from down here in my trench, standouts include:

• Eclipsys’ Peak Practice – best visual candy, great customizability
• Jay Parkinson and his creative Hello Health – Web 2.0 style, “intuitivity”
• Doctations – online implementation, share-the-sandbox inclusivity
• TeleAtrics – little known with one of the best physician or patient/parent visit summary note formats – not too big, not too small, juuuuust right
• Medicomp’s new CliniTalk – simpler, yet far more powerful coded data collection via voice, type, or pen click
• athenahealth’s athenaCollector – exudes billing and practice management power
• Medicity’s Care Collaboration Platform – share, share, share

Why hasn’t some clever bizhead figured out that the potential for a really slick open source EHR/PM, marketed and supported correctly, is astronomical? Vendors say up front fees are not the moneymakers, that ongoing support services are what generate profit. Still, the majority of my non-tech physician colleagues cringe far more at initial EHR cost figures than at the support fees. Lower the threshold for entry; make a visually pleasing tool designed for normal peeps, not gadget geeks; provide education and support par excellence – these would seem a recipe for sweeping adoption and profit.

Small community docs and hospitals could certainly use a truly functional, low entry threshold product to help them cross the digital divide for their two-thirds of U.S. healthcare provision. They need a playing field equalizer, because current vendor offerings are built mainly for the big boys. It’d be nice if some bIg BeheMoth-sort would see the value in thousands of small community sales globally, but if not (and not meaning to be insensitive) then come on, all you out-of-work developers and designers out there…wake up!

During the current economic slump: 1) band together; 2) steal a few from column A, a few from column B, etc.; 3) put together an EHR that really will help the befuddled medical masses with a healthcare tool we could all actually use; and 4) create yourselves some jobs while helping save the entire U.S. healthcare system – hell, the whole global economy – to boot!

Still to come:
Step 5: Verdant Health (Lush, Full, Eco-friendly, Yet More Jobs – “Green” in Every Sense)

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.