Intelligent Healthcare Information Integration 5/16/09

Ray Says, “It’s Not My Fault”

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

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

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

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

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

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

Thanks, Ray.

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

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News 5/14/09

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

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

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

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

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

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

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

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

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

E-mail Inga.

News 5/12/09

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

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

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

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

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

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

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

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

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

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

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

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

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

E-mail Inga.

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.