Cybernetic Medicine

Cybernetics, the scientific study of control and communication in the animal and the machine, used to be the stuff of science fiction.  Today, thanks to a Faustian bargain between corporations, regulators, and politicians, it is defining medicine.

Every day, the exponential explosion of data entry and regulatory requirements doctors endure boggles the mind, all in the name of "health care." 

Feedback is critical to field of cybernetics.  And when Medicare's straps have you by the balls, you comply.

No longer is it good enough to learn a diagnosis or procedure code, doctors must attend online courses to learn how to use a new "calculator" to determine a more proper code.  After all, there will soon be over 70,000 of them.  Each more specific than the other, each more ridiculous.   There are five data-entry fields to click on that calculator, each another tiny, yet time-consuming decision to be made, just to determine a code.  No doubt teams of clever twenty-something computer programmers are overjoyed with their coding calculator and the way it pops up automatically on our screen when needed, then disappears.  So pretty.  So cool.  See how easy they've made it to complete that regulatory requirement?

And this does not begin to address the increasingly algorithmically-driven electronic medical record and procedures envisioned in the years ahead. As if all things can and must be perfectly defined and quantified in medicine.  No mistakes.  No judgment needed.  No need to type. Just close your eyes, click a few buttons, and follow the pathway.  Stop thinking. Just do it. Enter the data. Resistance is futile.

After all, it's about the money...

... and perfect physician cyborgs.

Feel that strap tightening?

-Wes

E-Flooded

I have been a way from blogging for a bit - tried to clear my head a bit with a vacation skiing - left the computer at home, disconnected (as best I could), and had the luxury of feeling the knees working less fluidly than they had before, but still had some fun for a brief 3-day stint.  It was nice to notice that there's a whole world out there - beautiful mountains, fresh air, nice friends.  All things considered, I am pretty lucky to have a stable job, appreciative patients, and a fulfilling career.

But it didn't take long after my return to work for me to feel flooded again.  Two days after returning to work, it was like I never left.  Perhaps it's like that for most busy folks, but somehow the world of health care delivery feels more frenetic than ever.  The in-basket messages,  the mountains of results, the re-scheduled patients on top of those already scheduled, the seemingly endless phone and e-mail messages, the late-night consults after a full day of procedures - all demanding time - it's bordering on crazy.  I have several nurse practitioners who assist, but the volume of electronic patient care that's happening now is overwhelming to even the most computer-savvy of us doctors.

And all of this communication is not compensated.  There are no "RVUs" for answering an e-mail.  There are no "RVUs" for speaking on the phone.  There are no "RVU's" for typing.  No "RVUs" for data entry and clicking a mouse.  Physician time means nothing to programmers and policy-makers.

It's a larger symptom, I think, of the new "efficiencies" built into the electronic medical record (EMR) that has become ubiquitous with the world of medicine today.  Information flies so fast and there's so much of it that it's getting almost impossible for doctors to keep up with the screen responsibilities, not to mention their care responsibilities.  The EMR is no longer just an EMR.  The EMR has morphed into  a scheduling agent, pharmacy, reminder pad, calculator, care pathway generator, instant-messaging service, a procedure orderer-by-proxy (and guideline) and a patient messaging portal that, aside from a 400-character limit, provides unprecedented  access to physician in-boxes and schedules. There are so many buttons that they no longer fit on a single screen and the "allergy" field no longer can be displayed as it's pushed out of the way by the name of the patient's insurer.  Add to this the constant and growing influx of patients (thanks to marketing pushes and programs to spur referrals), voluminous administrative meetings, and growing CME requirements, it's no wonder many of us feel flooded.  I work later than ever now thanks to these electronic "efficiencies," then find myself waking in the middle of the night wondering: Did I call Ms. Smith? Did I miss something? Did I put that order in? When am I going to do those result notes?

I think I'm suffering from post-traumatic electronic overload disorder (PTEOD).

Oh sure, we could hire another guy or gal to offload some of the work - maybe even hire a wasteful manpower-intensive scribe like those that work in some ERs that click for cash - but that really won't help stem the ongoing barrage of information that is now pummeling physicians and their care teams at an unprecedented rate.  Sadly, I don't see this trend changing anytime soon - the business case for the EMR is just too attractive for hospitals and payers.  Still, with the prospect of ICD-10 and it's 71,924 procedure codes and 69,823 diagnosis codes (that must be paired correctly lest doctors not be paid) just around the corner, I fear that physician stress, burnout and PTEOD will only increase as we are force-fed this diet of electronic overload without any reflection of what its doing to those who provide the care.

Ugh.  I need another vacation.

-Wes

Kicking Cans

The government is remarkably good at kicking cans down the road.

This is the single reason is why government-run health care costs so much.

For instance, we continue to kick the can down the road for the doctor pay fix. Time and time again, we see the Sustained Growth Rate formula fail to be overturned, and instead, Congress vote a few-month reprieve to pay cuts for doctors until they can find another way to either pay those who do the work, or cloak these paycuts in another, less visible and acutely painful way. Look, we all know it's coming: paying a few paultry percent more for primary care while slashing specialists payments 40% was lost on noone.

And now their kicking the ridiculously complex and overly obsessive medical coding scheme called ICD-10 down the road. This morning we hear the purveyors of this money making scheme, the AMA along with their co-dependents at the Health and Human Services claim they will:

“announce a new compliance date moving forward,” the agency says.

“We have heard from many in the provider community who have concerns about the administrative burdens they face in the years ahead,” HHS says.

As if they really care. Better yet, it's as if doctors were on really okay with this coding scheme, but just a little "administratively burdened."

Baloney.

Let me clear: doctors are NOT okay with ICD-10. We never have been. Nor will we ever be. It provides NO value to the patient experience. And let me be even clearer: the REAL reason this can is being kicked down the road is because there are not enough programmers in the world capable of debugging and writing the mounds of computer code accross the scores of information systems out there in the time allotted, nor personnel capable of training all the medical coders and the various permutations of "medical providers" out there on how to use this system.

The delay in implementation of ICD-10 and the inherent costs associated with its implementation and delay of implementation has NOTHING to do with doctors.

Yet this coding scheme and bureaucratic delays of things like the doctor pay fix and the implementation of ICD-10 has EVERYTHING to do with how expensive our health care system has become and how expensive government health care is in general. But you will never see the huge costs of all these delays and hand-wringing accounted for in a non-partisan budget office.

Yep, the reality of these inefficiencies within government-run processes are the poster children for why our entire US health care system is so expensive.

-Wes

The Idiocy of ICD-10: W22.02XD

In the interest of brevity and efficiency, I'll let this speak for itself:

It's not clear how many klutzes want to notify their insurers that a doctor visit was a W22.02XA, "walked into lamppost, initial encounter" (or, for that matter, a W22.02XD, "walked into lamppost, subsequent encounter").

If people want to know why they can't get an appointment in 2014 and why doctors are frustrated with our current health care system, look no further than ICD-10.

-Wes

Related posts: Ten Times the Fun or my favorite: If Lawyers Billed Like Doctors

Garbage In, Garbage Out

The question came up at a recent meeting:

“How many atrial fibrillation ablations did I perform last year?”

It was a seemingly simple request. One that our vast array of computer technology and Electronic Medical Record should be able to conquer in a few microseconds.

So after an administrator talked to the responsible Information Technology officer and they searched and scanned the appropriate clinical and billing files, a day later came the answer:

Exactly one.

My swollen legs can attest to the inaccuracy of this result.

Yet with the speed of the hospital intranet, the results were broadcast as gospel in an e-mail to those who needed to know. Decisions were being made. Projections for upcoming years decided.

Which lead me to ponder the obvious.

How helpful will our electronic medical records be in supporting clinical care if doctors, rather than administrators and hospital information technology geniuses, cannot access and utilize clinically relevant data?

It’s the classic case of garbage in, garbage out.

But of course our policy wonks have already anticipated this criticism. They understand the health care records are, by and large, free text. They know that computers don't work well with the nuances of the written sentence. So to compensate for this short-coming, they have plans to implement the Mother of All Coding Schemes to permit more accurate data queries, licensed and sanctioned by the American Medical Association, called ICD-10®. Our government needs this scheme, it was argued, to determine if the government is getting an adequate return on their health care investment dollar.

ICD-10®, it is promised, will provide for unprecedented data queries of electronic data, housed in data silos so large that even they will be the envy of Google. Once these highly specific codes are used, we are told, we’ll really be able to forecast clinical trends, pricing trends, and define value-added components of our health care delivery in America. We will be able to determine which patients need our most urgent clinical interaction, purchase the equipment for that interaction in real-time, and assure it’s delivered “just-in-time” to the hospital loading dock, saving countless dollars.

So they say.

Sadly, real life gets in the way of such promises. We see this all the time in clinical medicine. “Mr. Jones, if you just stop smoking and take these medications …”, only to see Mr. Jones “forget.” Coding schemes are like this when applied to free text databases. The coded information is only as good as the people capable of classifying and sorting clinical care into pre-specified code bins accurately, and to date, there has never been a prospective evaluation to see if people really can achieve the promised results of this tactic. Which is why doctors will be the ones who will be required to either code the visit, under penalty of fraud if we're inaccurate, or teach others to code the visit with the same accuracy required to assure "accuracy." One only has to look at the labyrinthine nature of the new coding to see where it falls flat.

But there is other more ominous problem with the EMR data queries that goes far beyond the codes: the software that uses those codes. Hospitals and doctors, you see, don’t have access to the software. It’s owned by proprietary companies whose employees are already overworked to add the next bell and whistle to their software to stay ahead of the competition in the Great Race to become the great National Electronic Medical Record System sanctioned by Congress. No one really knows if the software is programmed correctly, they just assume it is. If a doctor takes issue with results reported by the Great EMR System using the World’s Most Powerful Coding Scheme, the hospital administration is rendered impotent by the need to ask, pretty please, Mr. EMR vendor if he could check their results. To which, of, course, the EMR vendor adds the request to their ever-growing queue of similar requests with promises like “well, we’ll work on it when we have time, but changing things would affect ALL of the hospitals with which we have contracts so we’ll determine if the request is important enough to pursue first.”

God forbid doctors be allowed to design and review their own clinically-relevant data queries.

So there you have it.

What they're calling "clinically-relevant health care data queries" in the era of our new Electronic Medical Records. Data queries decided by others in the name of the greater good yet often completely useless to those of us providing the clinical care, yet full of great hope and promise for a brighter health care future...

... at least until a more accurate coding scheme with greater clinical relevance called ICD-11® comes along.

-Wes

If Lawyers Billed Like Doctors

Imagine if lawyers had to bill like doctors:

Beginning July 1, 2010, under the Legal Billing Obfuscation Act of 2009, lawyers will receive their payments for services rendered after approval by a central US government Payment Distribution Authority (USPDA). To receive payment from the Authority plaintiff and defendant complaints must be coded and filed electronically using the International Classification of Legal Complaints, 10th edition (ICLD-10), copyright © 2009, American Bar Association and Legal Proceeding Terminology (LPT) codes, copyright © 2009 American Bar Association. The full publication of each of these codes will be available in print March 1st 2010 and in electronic form on DVD in July 2011.

To familiarize lawyers with the new coding scheme requested by the USPDA, a small sample for the complaint of “Spilling” is shown below:

• Spilling 200
• Spilling, Water – 210
• Spilling, Water, Hot – 211
• with blisters 211.1
• without blisters 211.2
• Spilling, Water, Warm – 212
• Spilling, Water, Cold – 213
.
.
.
• Spilling, Coffee - 240.1
• Spilling, Coffee, Hot - 240.11
Spilling, Coffee, Hot, With Cream only - 240.12
• with blisters - 240.121
• without blisters 240.122
• Spilling, Coffee, Hot, With Regular Milk only – 240.13
• Spilling, Coffee, Hot, With 2% milk only – 240.14
• Spilling, Coffee, Hot, With Skim Milk – 240.15
• Spilling, Coffee, Hot, With Soy milk only 240.16
• Spilling, Coffee, Hot, With Sugar only - 240.17
Spilling, Coffee, Hot, With Artificial Sweetner (of any type, including, but not limited to Nutrasweet, Spenda, Sweet ‘n Low) – 240.18
• Spilling, Coffee, Hot, With Cream and Sugar 240.16
.
.
.

Pairing of improper complaint codes with legal proceeding codes will result in non-payment. “Up-coding” of legal proceedings shall constitute grounds for prosecution with some additional fines imposed by the IRS, as determined by the Office of Health and Human Services. For instance, pairing a legal complaint of “Spilling, Coffee, Hot, with blisters” to and of those of Divorce, same gender, living apart, male (or female) (shown below) will result in non-payment.

• Divorce: 100-199
• Between husband and wife 100.1
• Between same gender couple, living together, male, 100.011
• Between same gender couple, living together, female, 100.012
• Between same gender couple, living apart, male, 100.021
• Between same gender couple, living apart, female, 100.022
.
.
.

Valid code pairings for spillage include Accident codes (0010-0059), Assault codes (4400-4499), or Battery codes (5500-5599) provided documentation supports the requests for payment.

-Wes

1,170 Angioplasty Codes

It's coming to a billing system near you.

And why do we need so many? Well, because:

"... under the new system, medical practitioners can choose among 1,170 coded descriptions that pinpoint such factors as the location and the device involved for each patient."

Or how about this reason:

"Hospitals, insurance companies and many doctors say the planned coding system is necessary to keep up with the host of new medical developments that emerge every year."

"Many" doctors? What the...? There is NO WAY "many" doctors are advocating for this. What does "many" mean in this context? While "many" can mean more than one doctor, I hardly think it means the majority. What doctor, in their right mind, wants to become a bureaucratic sycophant for the insurance industry?

Let's be clear here: this coding scheme is not sanctioned by "many" doctors except those that have crossed the health care employment boundary as hospital administrators.

This coding extravaganza will cost time, money and resources as physicians and their patients scramble to unlock the intricacies of the scheme to assure their patients receive health care. The system is sure to result in increased billing errors:

Some medical-industry officials also are concerned that consumers could see, at least initially, an increase in billing errors. That can lead, for example, to overcharging of patients, or an insurer denying payment for a claim because it was submitted with an incorrect code. Some officials also expect an increase in billing fraud and more delays in payments to doctors and consumers.

Trust me, "many" doctors do not want this.

-Wes

Ten Times the Fun

According to the bureaucrats, if you want to impose "cost saving measures" to correct our complicated health care system, do everything in your power to make it more complicated.

In fact, make it at least TEN TIMES more complicated.

Take for instance, our current coding scheme for classifying diseases called ICD-9 codes. (ICD-9 stands for the ninth revision of the "International Statistical Classification of Diseases and Related Health Problems"). These codes are required on every insurance claim to justify a payout on behalf of the patient. If a procedure code does not match the appropriate disease code on an insurance claim.... BOOOIIINNNNGGGG, the insurance claim is denied, and Medicare and the insurers save money.

These codes are a picture of clarity. I mean, let's hear it for 427.0! Oh, baby, I can get my head around that code, can't you?

What, you don't know what that means?

Why, "SUPRAVENTRICULAR TACHYCARDIA!" I mean, I knew that, why didn't YOU? Sheesh! Any REAL doctor knows THAT code. After all, it makes so much sense, right? And 427.1? Why heck, any well-respected doctor should immediately be able to intuit that the code is used to denote VENTRICULAR TACHYCARDIA! What, you're lost? How can that be? I mean, it's so CLEAR!

And on and on it goes, some 17,000 codes for 17,000 kinds of ailments.

But for bureaucrats, 17,000 codes are not enough. They want MORE! Many, many more. And so, ladies and gentlemen, they have announce the introduction of...

... drum roll, please ...

... ICD-10!

Yep! Welcome to the world of the soon-to-be-enacted NEW AND IMPROVED 10th revision of the ICD codes with a staggering 155,000 codes to be implemented on 1 October, 2011!

Imagine, 290 codes just for diabetes! Yeeeee haaaaa! Diabetes with foot ulcers on the right foot gets one code, diabetes with foot ulcers on the left foot gets another code, diabetes with foot ulcers on both feet, but not involving the shins gets another code... I mean, a new code for every nuance of disease! You get the drift! Isn't this SPECIAL? Just think of the COST SAVINGS those clever bureaucrats have found!

Oh, wait.

Someone actually looked at the cost to implement this "cost-saving" coding scheme for doctors, and here's what they found:

The total estimated cost for a 10-physician practice to move to ICD-10 would be more than $285,000. These expenses include:

• Training expenditures are estimated to total $4,745


• New claim form (superbill) software $9,990


• Business process analysis $12,000


• Practice management and billing system software upgrades $15,000


• Increases in claim inquiries and reduction in cash flow of $65,000


• Increased documentation costs $178,500

For a small, three-physician practice, the total cost to implement ICD-10 is estimated to be $83,290, for a large, 100-physician practice the estimated costs to implement ICD-10 is more than $2.7 million.

Heck, I'm on board, aren't you? Especially since most stand-alone physician practices can't even afford yesterday's electronic medical record that will be obsolete before it's installed. Look, for instance, at this comparison of a family practice doctor's current 2-page "superbill" that will expand to a 9-page "superbill" using the newly proposed coding scheme.

Crazy.

But lets not fool ourselves. This is exactly what the government wants: more complexity and bureaucracy in the name of lower "costs." One only needs to see how the government calculated their "cost" savings for justifying the massive increase in complexity to the coding scheme:

Benefit Assumption 1: Based on the data provided in a recent AHIP report the percentage of pended claims was assumed to be 14% of total claims.

Benefit Assumption 2: Pended claims will be reduced by 0.28% (minimum) to 0.7% (maximum). Using the research and interviews, it was assumed that the pended claim percentage, currently 14% (Benefit Assumption 1), would be reduced through standardization.

Benefit Assumption 3: Reduced manual intervention will reduce the costs for providers by $3.20 per call and for plans by $1.60 per call. Manual intervention is required to resolve pended claims and both Healthcare providers and Health Plans incur these operational costs.

Yep, there you have it. CMS has justified the most massive expansion of electronic coding so "providers" and massive health systems can get their money without having to pick up the phone.

But just in case doctors aren't too keen about the complexity and expense of electronic medical records for their office due to the carefully-planned obsolescence of new systems, doctors are also being forced to e-prescribe next year in order to gain 2% more of their Medicare payment they were due.

My friends, soon we will see that the Beast has won. Independent stand-alone physician practices will soon be a thing of the past, brought to their knees by overbearing electronic billing and prescribing regulatory requirements. In their place will be physician-employees of major health care systems that are capable of purchasing computers, personnel and electronic reimbursement software upgrades annually, while they are subject to data-mining algorithms to assure "efficiencies" and "effectiveness" and "quality," all in the name of cost-savings.

Too bad its the patients who will ultimately have to bear the costs for this.

-Wes