Intelligent Healthcare Information Integration 6/8/09

Feeding the Fire of Non-Participation

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

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

To wit:

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

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

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

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

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

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

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

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

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

Dr. Gregg Alexander is a grunt-in-the-trenches pediatrician and geek. His personal manifesto home page…er..blog…yeh, that’s it, his blog – and he – can be reached through http://madisonpediatric.com or doc@madisonpediatric.com.

News 6/4/09

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

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

Allscipts adds SYNNEX as its latest MyWay distributor.

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

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

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

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

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

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

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

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

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

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

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

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

E-mail Inga.

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Joel Diamond 6/2/09

Controlled Medical Vocabularies

In my last post, I discussed how our current coding systems just don’t suit the needs of everyday working physicians. For some reason, it got me all nostalgic for the good old days of paper records. Nothing like curling up in front of the fireplace with an old novel. Ahh … the texture, the smell …

OK, the reality of paper charts: falling apart, disorganized, and an odor best characterized by the last body orifice examined.

My EMR records are so much more complete and accurate, yet I will admit that there are subtleties that are often lost. For instance, my long-since retired, older partner was fond of writing F.I on the front of certain patients’ charts. This was to boldly remind him that a patient was a “(expletive deleted) idiot”. I remember when I first went into practice, one of his patients was staring at the outside of her chart while I was talking. “Dr. Diamond”, she asked, “what does F.I. mean on my chart?” Thinking quickly, I blurted out that my aging partner liked to label only the charts of his favorite patients, designating them as “fine individuals”.

Then there are the long-lost abbreviations written in the margins of countless charts — meant to convey a certain nuance that is sadly missed in today’s templated notes. Most of us fondly remember the sign-off on complicated VA patients: AMF YOYO— an encouraging “adios, mother (expletive), you’re on your own”. The essence of a patient’s condition could often be wrapped in the gallows humor of a cryptic abbreviation: ART (assuming room temperature), FTD (fixing to die), or an order for PBAB (pine box at bedside).

The term SWAG written next to a differential diagnosis conveyed to the reader that this was just a “scientific, wild-ass guess”. The conclusion to a discharge summary, TTGA (told to go away) somehow told the real story. An opening description such as LOLINAD (little old lady in no acute distress) will be missed as much as the politically incorrect description of the pediatric patient’s parent, GLM (good-looking mom).

Don’t get me wrong, I strongly advocate the use of CMT (controlled medical vocabularies). Codifying information in reproducible terminology is necessary for a true longitudinal record, which can be used for analytics and research and effectively allows communication amongst the health care team.

It’s just that some days, I miss chuckling as I enter the exam room — wondering how I’d explain my old partner’s unabashed label of his opinionated and misinformed patient as ABITHAD (another blithering idiot, thinks he’s a doctor).

Joel Diamond, MD is chief medical officer at dbMotion, adjunct associate professor at the Department of Biomedical Informatics at the University of Pittsburgh, and a practicing physician at UPMC and of the Handelsman Family Practice in Pittsburgh, PA. He also blogs on interoperability.

News 6/2/09

From Deborah Peel “Re: security. Today’s interconnectivity can also put patient data in jeopardy. It’s time for all physicians — not just plastic surgeons — to wake up to the risks of using HIT systems without ironclad security or consumer control over data use. The national professional organizations for medicine and nursing are AWOL on the key policy issue of putting their patients first by restoring the Hippocratic Oath and privacy rights in electronic health systems.” The privacy rights advocate is referring to this article published in the Cosmetic Surgery Times, which stresses the need for physicians to safeguard their healthcare IT systems against patient privacy breaches. The article quotes an attorney who says, “The cost of civil penalties or remediation resulting from a data breach may add up to significant dollars, but the more significant loss is the loss of public trust.”

QSI, the parent company of NextGen Healthcare Information Systems, reports flat net income for its fourth quarter ending March 31. Revenues rose 29% to $65.8 million. The company said results were affected by delays in purchasing decisions related to ARRA uncertainties.

The Texas legislature hopes to attract more physicians to underserved rural areas of the state with the passage of new medical school loan repayment bill. bill. If signed by the governor, it will set up a fund to repay up to $160,000 in student loans for any medical school graduate who agrees to practice in one of the rural counties of Texas for at least four years. The funding will come from a new tax on smokeless tobacco products.

Meanwhile, the American College of Physicians and others are lobbying Congress to provide scholarships and loan repayments for students pursuing careers in primary care specialties. The Preserving Patient Access to Primary Care Act is designed to address critical shortages in primary care providers.

Maryland becomes the first state to enact legislation requiring private insurers to offer financial incentives to health care providers for adopting EHR. The same legislation requires the establishment of a statewide HIE.

The 20-provider Horizon Eye Care (NC) selects SRS ePrescribing and OpenPath technology for its seven-office practice.

Check out our new “Industry Events” link in the green column to your right. Click to view the HIStalk calendar that is designed to keep track of industry activities. Readers can submit their own events (subject to approval). The calendar includes links some cool features, including maps and current weather. You can even download an event to your calendar.

Also on HIStalk: to date, 91% of HIStalk readers responded “no” to the question, “Is CCHIT free of HIMSS influence?”

A physician from the Bronx who received free EMR software through NYC’s Primary Care Information Project claims the move to EMR was “one of the best decisions” he ever made. Dr. Sumir Sahgal see improvements in his practice, particularly in the monitoring of medications for elderly patients. Sahgal was one of 200 doctors serving underprivileged communities who benefited from the Primary Care Information Project. Though the software was free, Sahgal and his four partners spent over $40,000 in out-of-pocket costs plus the cost of PCs.

Tenet Healthcare announces the creation of MED3OOO Practice Resources, a joint venture with MED3OOO that will focus on providing services to physician offices. Tenet, which has a 20% stake in MED3OOO, will offer services to physicians in the 12 states in which Tenet operates. MED3OOO Practice Resources will provide HIT and management services to participating physicians, which will include most of Tenet’s employed physicians.

Though many “house-call” doctors are slammed for being available only to the wealthy elite, here is one doctor that seems to break the mold –- on several levels. Dr. Dale Hamrick didn’t decide to become a physician until age 39. In reading the article in the local Charleston, NC paper, it sounds like most of his income is from Medicare and he does not charge any type of membership fee to be part of his practice. Because he covers a wide geographic area, he only sees 10 patients some days. He carries a laptop (presumably for chart notes) and is currently looking at voice recognition software to save time. How can you not like a doctor who wears jeans and works out of a pickup?

Natalie Hodge is a pediatrician offering a more traditional house call, concierge-style practice that relies heavily on technology, including a pediatric web portal, secure electronic medical records, podcasts, and iPhones. In fact, the Personal Pediatrics practice website touts its use of “21st century technology.” Hodge claims her “old model” office-based practice used to cost $200K a year to run, versus $50K with the new model, with both providing the same revenue.

If you are an employer who prefers your employees work even when they are sick, you might want to check out Medicine At Work, which provides physician services in the workplace using telemedicine technology. The physician connects remotely while a local paramedic assists with the exam on site with the patient.

Leonard M. Fuld, the head of competitive-intelligence firm Fuld & Company, predicts that Obama’s planned acceleration of EHR adoption will drive consolidation in HIT and threaten many small physician practices. Fuld predicts that “hundreds of thousands” of small practice doctors could be forced to join larger groups, largely due to the expense and complexity of adopting EHRs.

Practicing physician William Carlson is named chief medical officer and director of PHR vendor Connectyx Technologies holdings Group. Carlson is an orthopedic surgeon with a practice in Florida and also serves as president of the medical staff at Martin Memorial Health Systems.

Humana beats out Aetna and Cigna in athenahealth’s fourth annual Payerview Rankings. The rankings examine which insurers are paying the fastest. The overall survey results indicate that the insurers are paying physicians 5.3% faster and denying 9% fewer claims than last year.

HealthLINC, an HIE based in Southern Indiana, is awarded federal funds to implement Axolotl’s e-prescribing technology for Bloomington-area physicians and pharmacies.

E-mail Inga.

News 5/28/09

If Massachusetts lawmakers have their way, “sorry” will no longer be the hardest word for doctors to say. The state is considering a bill that would let doctors say “I’m sorry” without admitting they made a medical mistake. Expressions of condolences or compassion would be inadmissible as evidence should a medical malpractice lawsuit be filed.

Southwest General Health Center (OH) selects Allscripts Professional EHR for its 30 employed physicians. The practice will deploy the EHR via the Software as a Service model and integrate the Allscripts application with its existing MicroMd practice management system.

divx twilight

Retail clinics in grocery stores and retail chain stores seem to be following the money, with most setting up in regions with higher median incomes and lower poverty rates. No surprise that Wal-Mart, CVS, and others prefer areas that offer better odds of getting paid.

We’ve recently mentioned incidents involving paper medical records showing up in dumpsters and recycling centers. Now a Michigan doctor is being made to pay $350,000 to settle a lawsuit with the Michigan Department of Health, which charged the doctor of improperly disposing medical records from a now-defunct hospital. The doctor burned the charts at his farm, which frankly sounds like a far better solution than the dumpster and recycling options. I suppose in all these cases people are trying to save a few bucks by not hiring a professional contractor to get rid of the charts. Hasn’t anyone ever heard of a paper shredder?

EMR/PM vendor gloStream secures $7.5 million in series B financing to bolster its development, marketing, and sales efforts. gloStream plans to hire additional staff across the company to further develop and promotes its Microsoft Office-embedded EMR and PM solutions.

The Richmond Academy of Medicine (VA) aligns with NextGen reseller TSI Healthcare to offer Academy members preferred pricing on EHR and billing services. The Academy is an alliance of 1,700 doctors in the greater Richmond area.

Medical billing companies PracticeMax and MedaPhase merge to form one of the largest regional billing service companies in the southwest. The new entity, PracticeMax, will focus primarily on revenue cycle management needs of ER and urgent care physicians, along with certain other specialties.

The gloves come off in the continuing debate of the role of HIMSS and CCHIT in HITECH payments. The Washington Post ran two semi-critical articles suggesting that HIMSS used its lobbying influence to convince the Obama administration to spend billions on healthcare IT, then pushed CCHIT (which it was involved in creating) as the certifying agency for EHR products. In an apparently unplanned third article, the Post ran some heated comments from CCHIT head Mark Leavitt in response to these comments from Dr. David Kibbe: “One has to question whether or not a vendor-founded, -funded and -driven organization should have the exclusive right to determine what software will be bought by federal taxpayer dollars…It’s important that the people who determine how this money is spent are disinterested and unbiased…Even the appearance of a conflict of interest could poison the whole process.” Leavitt’s response: “For months, I’ve been ‘turning the other cheek’ to Dr. David Kibbe … his repeated use of falsehoods and innuendo to attack CCHIT have found an audience in the national media, reaching a level that can no longer be ignored. By implication, he demeans the integrity of everyone who has contributed to that work – and I must rise to their defense.” More of Leavitt’s comments are in the graphic above.

Allscripts CEO Glen Tullman earns a “Best of Illinois” award from the Juvenile Diabetes Research Foundation Illinois chapter. Tullman, whose son and niece have Type 1 diabetes, was recognized for his service on the Illinois Board of Directors, on the International Board, and for his support of the organization’s efforts in developing an artificial pancreas. Glenn’s brother Howard wrote about the event and took the picture above, which I found on his site.

Memorial Health University Physicians (GA) selects McKesson’s Revenue Management Solutions for billing and practice management. The group will deploy McKesson Practice Complete, which includes the Horizon Practice Plus financial application and RelayHealth Ambulatory Claims Manager.

About 150 Alabama physicians are pilot testing a new e-prescribing tool made available from the state’s Medicaid agency. The e-Rx technology is part of QTool, a web-based EHR and clinical support tool developed by ACS to support Alabama Medicaid’s statewide EHR system.

Here is an interesting article, geared to the average consumer, that explains some of the key benefits of EHR. The stuff mentioned sounds great: fewer trips to the doctor’s office because EHRs allow you to converse with your doctor online; personal access to your medical records online, regardless of where you are in the world; and no more dragging X-rays (or another diagnostic test results) from doctor to doctor because everyone can see them online. Maybe the average consumer wants to believe all that, especially since their tax dollars are going to subsidize the purchase of EHRs. The rest of us are left wondering how long will it take to achieve nirvana.

Properly implemented HIT, including EMRs and electronic prescribing, is a requirement for changing the model for primary care that is in place today. So concludes a New England Healthcare Institute report that claims HIT improvements would increase physician time during visits, provide timely access to information, and aid in the overall coordination of care. The study calls for a number of additional innovations to improve the quality of primary care, including patient-centered medical homes and better pay-for-performance initiatives.

E-mail Inga.