Joel Diamond 9/14/09

Random Thoughts from a Traveling Physician

Maintaining a private primary care practice while being a healthcare executive for an international company is both rewarding and challenging. Travel and interaction with doctors and nurses in diverse environments is extremely valuable in gaining new perspectives on healthcare, but often requires creative processes to remain accessible to my patients back home.

A few weeks ago, I was waiting on line to board an airplane in Pittsburgh. By chance, several of my patients were on the flight. One reluctantly told me that he felt guilty about not scheduling his overdue colonoscopy and another mentioned his need for prostate exam. A stranger who was in line, actually asked me if I “enjoyed doing that kind of thing” and should he be” nervous” with his own doctor. I couldn’t help but reinforce his anxiety by saying, “Only if you feel both of his hands on your shoulders during the examination”.

When I finally took my seat, the gentleman next to me said, “I couldn’t help hearing those people talk to you. It must be strange running into patients like that.” Thinking that this was going to turn into a conversation about accessibility and dedication, I was disappointed to hear his next question. “How does it feel when people see you and only think about their ass?” Oh well, so much for the glamour of a traveling physician.

On a recent trip to the Netherlands, I took my 16-year-old son with me, hoping to enrich him culturally. Unfortunately, our brief stroll through Amsterdam’s famed Red Light District became the prime focus of discussion when talking to his friends back home. My wife still quizzes him about details of the Anne Frank House and Reikmuseum just to see if we really did doing anything truly cultural.

The truth is that one must turn every situation into a meaningful learning platform for teenagers. For instance, when my son noticed a leather-clad prostitute wearing a dog collar casually sitting in her shop front window, I seized the opportunity to point out that she paid income tax on her earnings along with a 19% VAT on each client. (Annoyingly, he challenged her clients’ ability to maintain invoices for services). Undaunted, I persisted by launching into a discussion about Dutch healthcare. I pointed out that, like all Dutch citizens, she is covered under a universal healthcare policy that she pays for by both private payments and taxes.

All joking aside, Jonathan Cohn, a senior editor at The New Republic, wrote recently about satisfaction with universal healthcare in Holland. His observations align perfectly with my own. He points out that in Holland, most people have long-standing relationships with their primary care doctors, and 60% of them can get a same-day appointment (compared to the US, where it is only 26%). And while the Dutch spend only 10% of their GDP on healthcare, they rank substantially higher than the US in several key indicators of health.

This really got me thinking about the whole issue of accessibility in heathcare. While walking along Amsterdam’s beautiful canals, I was actually interrupted twice by patient calls from back home. It was bit surreal to e-prescribe on my BlackBerry while so far away. Clearly technology, if used properly, is a key to patient-physician accessibility. Having access to my patients’ records through an EMR plus interoperability with the hospital IT system allows me to care for patients even during travel, but it is my patients’ access to my cell phone that makes them feel that I am always available to them. 

Now I know what you’re probably thinking — “access to cell phone!?” Yes, I know … this is not the norm, but it is precisely why my patients can tolerate my unusual schedule. As is the case with the Dutch, the issue of accessibility should not necessarily be a detriment of universal healthcare, but attitudes and processes must be creatively changed, much like in my own practice.

Flying home recently, a complete stranger sitting next to me was complaining about his elbow. It was red and swollen and I casually asked him if he was going to get it taken care of immediately when he landed. “Should I?” he asked. I told him that he had a fairly significant olecranon bursitis and it appeared infected. I explained that it would likely require drainage of the fluid plus antibiotics. He thanked me for the advice, but then looked at me and asked reluctantly, “I didn’t think to ask, but without insulting you … you are a doctor, aren’t you?” With a straight face I answered, “No, but I did stay at a Holiday Inn Express last night”.

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 9/10/09

The AMA turns to Facebook to improve communications with patients and physicians. You, too, could become a fan of the American Medical Association by clicking here.

I see that eClinicalWorks is hosting its national user conference starting this weekend at the Venetian in Las Vegas. They are offering about 50 different session topics and most seem pretty substantive. I see the handsome John Halamka, MD is a keynote speaker (will he wear black?) ECW is expecting about 2,200 attendees, which is almost double the number they had at last year’s inaugural event. If you are attending, send us updates from the field. Heck, this sounds like such a solid event, maybe I’ll crash it.

Medflow, a company offering and EHR for the ophthalmology industry, plans to integrate Eyemaginations 3D-Eye home patient education into its EHR solution.

The AAFP offers a new resource tool designed to help providers qualify for PQRI bonuses. The PQRIwizard is an online registry that helps physicians track patient data and, as a by-product, create the reports required to qualify for 2009 incentives. Available to AAFP members for $199; typical bonuses are estimated to be between $600 and $2,000.

If you are a nephrologist and want to participate in the PQRI program and report quality outcomes, consider the recently approved Fresenius Medical Care CKD registry. This registry is supported by the Health IT Services Group through its nephrology-specific Acumen EHR.

The Center for Technology and Aging hopes a new $500,000 grants program will spur the development of technologies aimed at improving patient compliance with prescribed medication regimens.

E-mail Inga.

HIStalk Practice Interviews Karen Zupko

Karen Zupko is president of Karen Zupko & Associates, Inc., a medical practice consulting and training firm in Chicago, IL.

I understand you’re starting a new radio show on ReachMD on XM Satellite Radio. What will be the show’s focus?

That show launched on July 17th and people can access those spots. The series is called Practice Success. They are three-minute spots highly focused on a positive step that a practice can take. In some cases, an improved use of technology to lower accounts receivables, to reduce denials. In some cases, positive steps to be taken at the front desk to improve collections. The most recent spot that launched this week is on predicting whether you’re at risk for an E&M audit.

Those are all the past spots. Obviously, it’s on XM160, but it also is at www.ReachMD.com. The interesting thing, I think, is that there’s radio, there’s the Web, and all of this is, of course, accessible on people’s iPhones, which is pretty cool.

Another person on my team is Cheryl Toth. Cheryl has a very cool Webinar coming up about using technology in the practice level to improve communication with patients. She is really our queen of technology. She’s the KZA Queen of Tech

So it’s not a show per se, but actually spots that come up on different times of the day?

The spots come up four times an hour, and then it may expand into a larger show. These are short bullets — take this action step.

Have you gotten any feedback from listeners?

Yes, because some of them come back to our KZA Learning Center. So people are following up on those links.

How do you think healthcare will look in the next five years?

This may surprise people. I don’t think that even if legislation passes, it’s going to look dramatically different. Why do I think that? Because I think all of these health systems, the healthcare delivery, as you travel around the nation — which I have done extensively since the late 70s — everybody’s not at the same starting line.

You have one experience when you go to the Mayo Clinic. There is electronic medical record, and when you leave, you leave with a jump drive with all of your test results, versus many other academic medical centers that have yet to adopt the technology, or, have done it on the inpatient side, but not for ambulatory patients.

I think when you look at the technology adoption on the ambulatory side, whether that’s a hospital-owned practice, a multi-specialty group, or a private practice group down to the solo practitioners, for example, doing simple things like checking eligibility, easy things that should have been common sense like checking the patient’s ID versus their insurance card to be sure that the person and the card match, it’s a slog. That’s how I would describe it: it’s a big slog.

There is progress. The stimulus money is going to cause some people to get on with it faster than they would have if left to their own devices. I think the growing number of young physicians entering practice who are trained in technology are going to have a big impact as they become the majority.

But am I looking for the world to suddenly change? I’ve been working in healthcare since 1973. I’ve been through more physician manpower studies than you can shake a stick at [laughs]. Just like every five years, I expect somebody to pronounce with great definitiveness, “We have too many doctors.” “No, we don’t have enough.” “Too many.” “Not enough.” It’s like the tide goes in, the tide comes out. So it’s kind of where I sit.

Will there be major changes to the way doctors get paid or the type of insurance patients use?

I think that there are people, as we speak, looking at different payment options that are going to definitively reward people who have thought about cost, who have thought about collaboration, who have thought about the benefits of a central record, so when you look at those proposals that say, “We’re going to pay everybody for doing this hip, or doing this knee, or doing this heart, and this is the amount of money, and you all are going to figure out how you’re going to divide that up.” I think it’s pretty clear in all of this discussion that paying doctors based on volume of services provided hasn’t proved to be particularly successful.

So that system may go away?

I think it’s going to be reshaped. Again, it’s so vast. You have to be very careful about the law of unintended consequences, you know, like you push here, and it causes four bubbles over there that you didn’t really think about.

I don’t know where you were then, but when Oregon began discussing the fact that under Medicaid, not everybody was going to have everything. There wasn’t the money. So we’re not paying for the removal of benign lesions — benign lesions are benign. So that was probably 15, 20 years ago. It caused a lot of stir.

I think that the disingenuous elements that have been inserted into the current considerations. Those people should be ashamed of themselves. Death panels — I mean, please.

What type of IT tools do you think are a must for every doctor’s office?

Well, first of all, I think they need a computer.

To do what?

You absolutely have to have a computer to do more than e-mail. We should be doing all the scheduling, we should be using these cool, nifty tools such as the functionality offered by companies like Medfusion. Patients should be registering online. That data should then be dumped to the practice management systems. I’m working with practices to do that.

Companies like A-Claim that allow a practice to check the eligibility, that allow you to determine if the deductibles been met, what the co-pay really is, and is that service covered. Companies like RealMed and A-Claim both that allow for adjudication of claims while the patient is standing there.

We still go to practices that are not filing electronically because of the cost, unbelievably, and therefore, they are not getting electronic remittance, and not getting electronic payments, which therefore require that you have more people in the business office doing busy work. You would want to be using automated systems that take a promise to pay and turn it into the reality of payment.

I just had a conversation with a doctor today about meeting with his billing office staff. They have a half million dollars in receivables. It’s just totally, completely inefficient and incompetent. And then, if I get the business side done, then I would have the money certainly and price would not be the biggest objection to doing the electronic health record.

We go to practices that have a robust computer system, and somebody’s just decided to go dumb and not figure out how to do PQRI, or get the credits from e-prescribing. We think 4% of your Medicare money on the table — I mean it’s just hugely expensive.

That’s not an IT issue, that’s a personnel issue.

They can’t figure out how that is going to work. It is an IT issue. You know what, there are very few things, I think, as we go on, that are just an IT issue. I think in many cases — let’s do this as a summary statement — the technology is ahead of the skill set of the people who have to use it. We’ve got very sophisticated tools, and very unsophisticated users.

Are you saying the tools need to be easier to use or we need to get the personnel up to speed?

I think it has to be a combination of both. I think the description of how to do PQRI was rather poorly articulated by the government to start out with. And then some people tried, and were unsuccessful, and then they just say, “What the hell with it, then?” Does that make sense to you?

Yes. So, is the EMR an essential tool?

If you were a young doctor starting out in practice, then I would say absolutely, positively yes. If you were a six-doctor group with receivable problems, were an update or two behind on the practice management system, and have a lot of business process issues, I’m probably not going to tell you to race to implement the EMR at this moment. I think there are just so many things that you can try to do while the practice is seeing a full load or a full load plus of patients.

That may mean they’re going to leave some of that ARRA money on the table.

Right. I think practices have to up-hire. They’ve got to look at the level of people that they’re hiring. They have to buy more advice out in terms of tech. Do you understand that in many of these practices, the back-up is being done on a tape that sits on a shelf three feet away from the computer? I could not make this stuff up.

So the sophistication is not there?

Well, even if somebody can say, “I understand this is a problem,” — and I’ve got such a person right now; she is very articulate about what the problems are. She is not a technology wizard. She said, “I’ve got this problem, and it’s on this server, and that server has this issue; I need this fixed. I’m not even sure who can help me.” Then she calls two tech companies; one comes up with a support figure so unbelievable, something like $8,000 a month. The other one comes back three times and can never quite take notes about getting the story down, and they’re tech support. So it’s rather frustrating, to tell you the truth.

What’s the answer for the average doctor’s office that wants to move forward in technology? Outsource it?

Outsourcing what piece of it? You do have to outsource the hardware support and the backup. I would say one clear and positive thing that anybody reading this should do, and that is, please, double check, filled with skepticism, that your backup is as good as it should be and needs to be. If a comet fell out of the sky and hit your office while you were not there — you were at home sleeping — do you have the backup to be able to say or put out on the Internet, “Hey, we’re three blocks over in rented space, you can come and see us here,” and you can have everybody’s medical records and all the financial information.

I guess that’s the test. A comet hit your office. Boom! And if it’s not that good, and somebody’s not willing to put that guarantee in writing — “Yeah, it’ll take a couple of hours, we’d have to get the computers hooked up” — but the backup system is somewhere else, the backup tape is not three feet away [laughs] from the hard drive. Do you see what I mean?

Or somebody says, “Oh, it takes so long; we only back up once a week.” Can they afford to lose a week’s billing and scheduling? Medical records? No.

There’s been a whole series of emails back and forth between us and one of our consultants who’s now actually running a practice. All the doctors are using these iPhones to connect and the level of security that needs to be on the iPhones so if somebody picks it up, they can’t get into your EMR system.

And is it secure?

It depends. On her practice, absolutely, yes. There’s a lock and there’s an ID, but I’m going to guarantee you that for plenty of doctors, that’s not the case.

And you think there are still a lot of practices out there only doing backups once a week, for example?

Yes. Yes. I promise. I’m not naming names, but I’m not making that up, honey. [laughs]

Alarming.

Alarming, yes. And it’s not that these are dopey doctors. These are doctors medically who you would want taking care of you. We still have a long way to go.

Intelligent Healthcare Information Integration 9/4/09

From the Mouths of Babes

Ok, I know this is not directly an HIS tale, but with all the hubbub about healthcare reform here in the US and with healthcare information technology being touted as one of the linchpins to its reformation, I figure this is at least tangentially relevant … plus, maybe a bit of a hoot to boot.

In my office today with a mom and her three rather rambunctious young’uns, I heard perhaps the most brilliant idea for lowering healthcare costs and increasing patient care outcomes that I could imagine. Of course this little jewel didn’t spring from my lips nor those of the other adult in the room. It sprang from the untarnished brilliance of a six-year-old.

As the terrible trio was bouncing around, off, and into every nook and cranny they could find, the middle child, our precocious little thought leader, suddenly and without apparent provocation stated, “You know, if we kids would behave, you could probably charge my mom less money.” Exactly what inspired this nugget of insight to pop from his mouth, I can only conjecture. Regardless, it hit me like a bolt of enlightenment straight out of the Buddha himself.

Absolutely, there are parents I would gladly provide with the daily Blue Light Special if only they would encourage their precious darlings to not crayon my walls, tear my vinyl, rip my books and magazines to smithereens, ram chairs into walls, pull paper towels endlessly from the dispenser, etc., etc., etc. I would undoubtedly save significant wear and tear costs, which I would gladly pass along to healthcare crisis community tills.

Furthering this notion, what if we could charge everyone, adults, kids, and everyone else, a reduced fee for good behavior? You know, things like showing up for scheduled appointments, taking medications as prescribed, making healthier lifestyle choices, and just generally being punctilious. Wouldn’t that help lead to some of the “clinical outcomes management” goals for improving healthcare quality we all seek? Wouldn’t that help lower healthcare costs by bringing about improved health at lower cost? (Prevention versus pound of cure and all that.)

I guarantee you that if I could lower my charges for patients who are “being good”, I would gladly forego the $44,000 in reimbursement bucks; happily buy my next round of server, pen tablets, or EHR tools from my own coffers; and let the ARRA funds go toward building the bridges for data sharing and aggregation we all really need to accomplish something with all this information. Talk about your meaningful use!

"Out of clutter, find simplicity. From discord, find harmony. In the middle of difficulty, lies opportunity." – Albert Einstein

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 9/3/09

From: Curious George “Re: OSHA. I hear that hospitals are definitely on their toes in case an OSHA inspector drops in for a chat. Do you have any information on how many physician clinics are being targeted by OSHA? Have you heard of anyone who has and what their top five non-compliant issues were? I’d like to hear from practice managers what they are doing with regards to OSHA and how many have actually ever been audited, and what your take on this is. How serious is the threat of inspections are in our business because the articles I read were way beyond that book of MSDS pages most of us have stuck somewhere, but rarely update – not to mention all the other issues we could be hit with during a visit.” I’m glad to some asking around. In the meantime, I’d also like to hear from any practice managers (or doctors or consultants) who have opinions on this.

Patient-centered medical home models provide patients better primary care, without adding additional costs. Medical home patients had 29% fewer ER visits and 11% fewer hospitalizations than patients utilizing services in a traditional primary care environment. Group Health Cooperative conducted the one-year study and found that providers relied heavily on e-mail and made the most of technology, including EMRs. Providers also reported burn-out rates 20% lower than the control group.

Time magazine also took a look at the growth of retail clinics and says these practices “are rapidly becoming to the health-care industry what Fotomat was to the camera world.” The Fotomat analogy is particularly interesting given that Fotomat closed its online presence just this week. Of course, the cute little drive-up kiosks closed several years ago as Fotomat’s one-day photo developing service became obsolete with the advent of one-hour photo processing, then digital photography. Which all leads me to wonder if the growth of telemedicine will one day make retail clinics obsolete.

ZirMed introduces a new package that includes eligibility verification, claims management, and electronic remittance, targeting smaller practices with its new ZirMed One product, which essentially bundles three stand-alone products into one.

athenahealth’s Maine Operation Center is named one of the 2009 Best Places to Work in Maine.

Delaware’s Board of Medical Practice sets the maximum rates for copying patient medical records at $2 per page for the first 10 pages. The maximum per page fee declines based on volume and 50 cents is maximum per-page fee after the first 60. Though the costs are currently for both paper and electronic records, the board is considering lowering the fees for electronic records.

Pfizer agrees to pay the government a whopping $2.3 billion to settle a healthcare fraud case. Pfizer was accused of fraudulently marketing the anti-inflammatory drug Bextra and illegally promoting other drugs. It’s the Justice Department’s largest healthcare fraud settlement ever.

Atlanta Women’s Specialists puts out a press release about the benefits of its EMR system, which includes increased staff efficiency and safer care. The practice posts and flags abnormal test results within 24 hour, sends prenatal records directly to the hospital, and exchanges information with other medical practices via the Medicity Novo Grid. The practice will soon deploy smart phones as well.

We are looking for some guest columnists to share their knowledge on HIT in the ambulatory world. In particular, we’d love a clinician who is willing to share his/her EMR journey. If that’s not your thing, but you have other relevant insights to share, let send over an e-mail.

AHRQ plans to collect data from phyicians and pharmacies to identify what accelerates and what hinders the adoption of e-prescribing. The two year study will include interviews physicians, administrators, and pharmacists across 110 different organizations in order to determine what real or perceived barriers can be obstacles for physician practice and pharmacies.

Bridge Community Health Clinic (WI) partners with Healthport to implement practice management, EMR, and RCM solutions.  Bridge is an FQHC serving 21,000 patients a year across three locations.

E-mail Inga.