Joel Diamond 2/25/09

I love the HIStalk entries describing "odd lawsuits". Unfortunately, these seem to be an increasing norm in the business of healthcare. Those of us who practice on the front lines often feel that we have a malpractice target painted on our backs. It always amazes me how public policy experts downplay the huge financial burden of defensive medicine.

A few years ago, while covering for another physician, I was asked to see a young woman in the hospital who had been admitted for chest pain. She was scheduled for some diagnostic testing before I ever met her. During one of her tests, a small piece of equipment came loose and touched her chest, causing no harm. I was contacted and made arrangements for incident reports, investigation into procedures, and additional X-rays to rule out injury. 

After all this was completed, I visited the patient and met her for the first time. I apologized for what happened and assured her that I would personally follow up on the incident report that was filed. She responded to me, "No need to worry, Doctor, ’cause as soon as I leave here, I’m going straight to my lawyer". 

I told her that I was disappointed to hear that since she had no physical or psychological harm, and that additionally, I would most likely be named in any lawsuit as well. She then proceeded to tell me that I shouldn’t care. "That’s why you have insurance," she stated. After assuring that she was healthy, I turned to her as I exited the room and told her to "have a nice life".  

Sure enough, a few weeks later, I was served court papers. Amongst other grievances, I was accused of "insulting" her. Needless to say, the case was eventually dismissed, but not after lengthy hours taken away from patient care, replying to investigations, and attending depositions. 

When the case settled, I asked my attorney if I could actually pay a few hundred dollars to the plaintiff out of my own pocket in return for a half hour of her time. "Are you insane?" he asked. "Why would you do that?" I replied that I just wanted an opportunity to demonstrate for 30 minutes what an insult actually was.

I am frequently asked if I think that EMRs will have an effect on malpractice. In the situation described above, clearly not. There is no doubt, however, that improved documentation along with detailed access to patient data will be impactful. If we can figure out how to properly invoke clinical decision support, we can further mitigate risk. 

On the other hand, bad doctors will always find ways to exploit the EMR and use it for inappropriate short-cuts in both care and documentation. I have no doubt that there is a growing cottage industry of attorneys looking to exploit this technology in creative new ways to sue doctors. I shudder to think of what will certainly be a future accusation, "Just because you clicked an option that said ‘all normal’ does not mean that you actually performed a thorough exam." This is why I urge all physicians using an EMR to use extreme caution when documenting by exclusion.

Ending odd lawsuits is not something I can control, but improving the delivery of care to my patients is.

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

News 2/24/09

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

An HIT Moment with … Ann Mai

An HIT Moment with … is a quick interview with someone we find interesting. Ann Mai, MD is an internist in private practice in Irvine, CA.

How have your patients responded as you’ve incorporated additional technology into your practice?

My patients have been very positive about the additional technology. They enjoy receiving their results online and being able to communicate online with the office. Most have expressed that it saves them time and they feel that it makes the office more accessible at their convenience.

Do you think more doctors would use (and not just acquire) EMRs if the government helped make them affordable?

No. Doctors are stubborn and a small number may be motivated by government funding for EMRs and may acquire the systems, but to ensure use it is even harder. I know many doctors who have acquired systems out of their own pockets and never even implemented the systems. If there was an incentive to use the systems such as being related to reimbursement, this will most likely motivate doctors to use an EMR.

How do you respond to other physicians who resist technology such as EMRs and e-prescribing because they believe it’s too costly and time-consuming?

I agree EMRs and e-prescribing are costly and time-consuming in the early phases. The upfront costs deter most physicians; however, after being a user of these systems for over five years, I believe they not only save me time, but money, and made me more compliant in my documentation and billing. Perhaps they even self-generate more income because they make the documentation process more comprehensive and recommend more appropriate codes to bill. 

What’s been the good and the bad about implementing and using EMR, e-RX, and your patient communication tools?

Good – saves time, money, and the comprehensive documentation of each visit. Helps in coding for those who never learned how to in school (none of us ever did). Never have lost files in the office. Messages are not left on sticky notes that can get lost.

Bad – one wrong click of the mouse can bring up the wrong patient or wrong medication to prescribe or wrong diagnosis to label a patient with. Doctors and staff have to be careful with data entry and take frequent breaks to avoid eye strain and ergonomic problems – back pain, carpal tunnel …  Less eye contact with patients — patients do get used to this and appreciate it when they receive clearly written prescriptions or instructions. Our referrals are also electronic and the turn around time is instantaneous vs. "2 weeks in the mail" so the trade off of less eye contact is fair, according to my patients.

What type of changes do you anticipate for private practice physicians over the next 3-5 years?

Less reimbursement for same services, more e-prescribing mandates to reduce medication errors, and EMR mandates and interconnectivity with hospitals, labs …to reduce medical treatment errors. I hope that an EMR does become available free of charge to connect doctors across the country. Funding is either in the form of advertisements or government monies. I prefer to have no pens, paper products, and toys labeled with pharmaceuticals in exchange for EMR funding from the drug companies.

For solo practitioners, the EMR mandates may be so costly that these doctors may end up being extinct. Perhaps as a larger group the cost reduction will make acquiring and implementing an EMR more a reality.

News 2/19/09

The CIO of Springfield Clinic (IL) develops a registration kiosk that is being tested at a remote facility. Allscripts intends to resell the technology, which the CIO developed under his under his own separate company. Meanwhile, the clinic is planning to install another 50 units across its 200+ physician network.

A reader is asking for recommendations for an EMR system that would be appropriate and a good value for a cardiology practice of 6-8 providers. Your advice is appreciated! Post a comment at the bottom of this article. Thanks.

On Wednesday, Inga (along with about 1,500 other people) sat in on the HIMSS Webinar,  “American Recovery & Reinvestment Act of 2009." A key takeaway:  if you haven’t started implementation on an EMR yet, you better get a move on it so you can be using it in a "meaningful" way by 2011 (and line up your vendor resources before someone else does). Note that "meaningful" is not fully defined and will likely change multiple times over the next five years. And, of course there is the question of "what is a certified EHR?" HIMSS suggests the term means CCHIT-certified, at least initially. Also, you won’t get your money for quite awhile and some payments will be in the form of reimbursement. More to come.

Allscripts announces that Edge Health Solutions signed a multi-million dollar agreement to resell its EHR under the name "EdgeEHR." Edge Health Solutions currently provides practice management software running on the Mac OS X to 1,000 physicians and dentists.

A federal grand jury indicts three Miami area doctors and three medical workers for filing $10 million in Medicare claims for HIV drug infusion treatments that patients either didn’t need or receive. The physicians were also charged with laundering $5 million from the government payments.

CVS Caremark agrees to pay a $2.25 million settlement agreement over alleged HIPAA violations and deceptive and unfair trade practices. The FTC initiated an investigation into CVS Caremark following media reports that various pharmacies were discarding prescription drugs and personal consumer information into open Dumpsters. In addition to the resolution amount, the settlement requires CVS to implement a corrective action plan that includes employee training and sanctions for noncompliance.

Medical Justice offers a service to physicians intended to stop patients from participating in online rating sites, including having patients sign away rights to do so and preventing sites from publishing ratings of its members. Good thing or bad thing?

If you are a gambling enthusiast and tired of your same old medical iPhone applications, consider downloading Blackjack Card Counter. This tool makes card counting easy and thus helps you win more games. However, Nevada outlaws any devices to help count cards, so perhaps you’re better off sticking with Epocrates.

Primetime Medical Software announces that MDVIP, a national network of 300 physicians specializing in personalized preventive medicine, has selected its Instant Medical History’s medical knowledge base and questionnaire platform. MDVIP will integrate the knowledge base into its existing patient portal.

MED3OOO Group implements its practice management systems as an ASP for the employed physicians at Saint Francis Medical Center (MO). MED3OOO is also providing the hospital with revenue cycle and data management.  In case you missed it, we just recently interviewed MED3OOO’s CTO  Steve Ura, who provides some thoughtful insights on the company’s technology plans and the HIT world in general.

Payerpath founder and former CEO Jim Brady joins Marlin Equity Partners as an operating partner, with a focus on the healthcare IT and services sector.

A local business journal highlights some of the financial struggles currently facing Chicago-area practices. Declining revenues and rising costs are forcing more practices to consider selling off to hospital systems eager to add additional revenue sources. 

In regions where Zagat has begun rolling out its new physician review guide, doctors question its value and validity. Among the complaints: the ratings are too subjective and patients don’t necessarily understand or follow prescribed care plans.

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

Intelligent Healthcare Information Integration 2/18/09

10 Things I Hate About EHRs

1. So many EHRs look so Windows 95-ish…or like an accountant’s spreadsheet. Why? I dunno about you, but my brain doesn’t thrive on constant rows and columns.
2. I shun EHR vendor Web sites that require me to provide my contact information just to see a basic demo. I don’t have to give the Piggly Wiggly my phone number just to see an apple.
3. Most EHRs want you to drink from a fire hose when all you really want at first is a sippy cup.
4. EHR sales pitches and their pitchers always assure you that their particular product can cure cancer … while watering your tulips. (My tulips have all wilted, by the way.)
5. Template creation. ‘Nuff said.
6. EHR support or sales people who know less than I do about the product.
7. I’m gonna be really P.O.’ed if Obama money allows all the latecomers to buy EHRs for a song while I’m still paying off the second mortgage I needed to buy mine.
8. Most EHR vendors/creators think “clicking” somehow beats writing. But, when it takes 4,357 clicks to complete a 99213 visit and you can handwrite the same 99213 note in under a minute — meeting all coding requirements — well, how do you convince anyone that the trouble of workflow and habit change is beneficial?
9. We’re going to have “Minority Report”-style computing interfaces while EHRs will still be clunking along awkwardly, clumsily, bound to those old rows and columns.
10. Why (virtually) no Flash or PHP? Wouldn’t a little panache and Web 2.0-ness work in EHRs?
11. Faxed reports from an EHR-enabled ER or urgent care for one of my patients with an earache that uses five sheets of my paper and toner to tell me they got amoxicillin.

I know. That’s more than ten. But, as I alluded to in number one, “Damn it, Jim, I’m a doctor, not an accountant!” (Props to Bones.)

Dr. Gregg Alexander is a grunt-in-the-trenches physician and admitted geek. He runs an innovative, high-tech, rural pediatric practice in London, OH, and can be reached at doc@madisonpediatric.com.