Subspecialist Shortages and the EMR

The growing pay gap of non-procedurally-based subspecialties is threatening acute shortages of physicians in those fields:

A discipline built on spending time with patients to gather clues for a diagnosis, neuro-ophthalmology could become another casualty of a medical payment system that favors high-tech procedures over low-tech exams. The median income of a neuro-ophthalmologist at a teaching hospital is $200,000, according to the North American Neuro-Ophthalmology Society. That's a third less than most general ophthalmologists, who undergo less training but can see more patients, and do more pricey procedures, in a given day.

Many in health-policy circles have focused on how the current health-care payment system is helping create shortages among primary-care doctors, internists and others on the front lines of medicine. But often lost is how the system is endangering some of the country's most highly trained specialties as well.

Endocrinologists, rheumatologists and pulmonologists -- specialties that also don't involve performing many procedures -- face acute shortages. Many of the severest deficits affect children. Though nearly 300,000 children in the U.S. are diagnosed annually with juvenile arthritis, lupus or other complex rheumatic diseases, there are fewer than 200 pediatric rheumatologists to take care of them, according to the U.S. government's Health Resources and Services Administration.

And while this is concerning, it is only the beginning of the story.

New pressures are mounting on proceduralists (like gastroenterologists, cardiologists, radiologists and orthopedic surgeons) to increase procedural volumes. In multispecialty groups, the Medicare reimbursement system which devalues time with patients through its arcane and toxic documentation requirements shifts the burden of revenue generation to specialists to support other subspecialties that are less profitable. High-productivity specialists are now urged to do more to cover short-falls in revenue by their business managers. Even small fluctuations in practice volumes are seen in real-time thanks to electronic billing and the Electronic Medical Record (EMR).

The EMR has become not only the administrators' friend, but the proceduralists' as well. Thanks to text-generating "macros" (sometimes called "dot-phrases") the burden of the pre-op history and physical has been all but erased. If a patient has one cataract done thirty-two days ago (outside JCAHO's 30-day requirement), well then, no problem, just hit a few "dot-phrases" and presto! Away we go! "Dot phrases" can load up an empty history and physical form faster than you can say "operation."

But this push to increase procedural volumes, so easily tracked by the electronic medical record, puts additional burdens on today's procedural specialists and creates new patient-care conflicts. Increasingly, there is a push to tie physician compensation to "productivity." Productivity, then, becomes king. And for the patient who desires careful analysis of procedural options, careful decision making becomes clouded as salaries are increasingly tied to productivity.

So for doctors, the dark underbelly of the EMR for patient care is surfacing: despite its marvelous communication capabilities and efficiencies, the EMR has now become the quintessential business oversight tool and might just threaten the doctor-patient relationship as we've known it.

-Wes