Talking Heads

February, in case you haven't noticed, is "Heart Month" full of associations with Valentine's Day, love, peace and tranquility.  It's also a month to sell cardiovascular health care.

Everywhere you look these days are advertisements for the latest and greatest heart care, finest heart care facilities, touching stories of the latest cardiovascular intervention saving a life at this medical center or that.  Go ahead.  Type in "heart" as your Google alert phrase to see what I mean. 

Heart month, you see, is business month for most medical centers since the cardiovascular disease product line is sold more often than any other in medicine.  But what is good for the business of medicine is not always good for the reputation of physicians.  As one surgeon has wisely pointed out, physicians are devalued when breathless claims of magical health care delivery promised on TV can't be delivered. 

Most doctors say little about the problems inherent to this advertising trend.  We see no problem with advertisements for the latest drug or procedure on TV or the radio.  That's because doctors are becoming comfortable with their new subliminal marketing role for their new employers and as figureheads to quality.  

I worry that we doctors, overburdened with our new reality of declining pay, seemingly bottomless administrative meetings, data entry, coding requirements, and the million other regulatory changes that are detracting from direct patient care, are becoming comfortable (and worse, complacent) in our new role as talking heads.   We pretend that really there's no problem with "innovations" to care, when deep in our souls we know otherwise.    I get that we're all in survival mode right now, and perhaps this is why I'm concerned.

Recently the Wall Street Journal discussed the business case for using lower level providers in lieu of physicians.  The article discussed the "clash on proposed oversight" that exists when a less costly nurse anesthetist is substituted for a fully-trained anesthesiologist.  These capable nurse anesthetists don't want oversight.  They feel they can do their job just fine, thank you.  After all, they're the one's at the patient's side most of the time as the anesthesiologist flits in an out of several operating rooms instead of sitting in just one.  Is this the best quality for the individual patient to have a person with only two years' experience working independently?  Probably not.  Is it fiscally innovative for both doctors and hospitals to do anesthesia this way?  Absolutely.   Consequently, I wonder if tomorrow's "Top Doctor" will be a much-heralded clipboard-carrying oversight manager of an army of lesser-trained health care providers.

Perhaps these changes are inevitable given the realities of American health care delivery today.  In our rush to get more work done faster than ever, we use physician extenders to see patients first, then make cameo appearances at the patients bedside, more for PR (and billing purposes) than real clinical discovery.  Is this quality?  It seems that in our new world of upcoming Press Ganey patient satisfaction surveys linked to hospital payments, inpatient medicine is evolving to PR.  During the brief patient interactions, doctors had better smile, look good, and wash their face and hands lest the facade of quality fade.  After all, good doctor, big screen TVs, marble foyers, and extensive menu selections at the bedside can only get your hospital so far.  Yet if this trend is allowed to go to its next iteration, will image consultants be the next recertification requirement for physicians?

I wonder….

Sadly, conflicts such as these are only the tip of the iceberg.   For instance, instead of insisting that information technology giants and bureaucrats correct he horrible data entry requirements imposed by today's electronic medical records, many of us have succumbed to hiring costly scribes.  We justify the benefits of these scribes because they allow us to see and touch more patients, while not admitting that we have thrown up our hands to the root problem that created this mess in the first place.  Likewise, when physicians allow their administrators to purchase cheaper, inferior equipment or allow maintenance contracts to lapse in the name of "alignment" of doctors' and hospitals' financial interests, who are we serving?  Or as personnel ranks are slashed from hospital payrolls and patient wards consolidated, are our patients being served best? Can a nurse used to caring for post-surgical patients really manage a cardiac patient as well?

The list goes on and on.  While employee-physicians are losing our autonomy and ability to provide direct one-on-one patient care in all cases, there's a growing need to educate those who don't have a clue about patient care in hopes of improving that care without compromising its quality (if that is possible).  Perhaps more than ever, doctors are needed to fulfill a leadership role in the education of all factions involved in patient care - from administrators to ancillary care providers - about what is needed for their patients and when.  Doctors need to push to dismantle what is broken and organize those systems that work.  Being railroaded by a system that has changed way too soon and way too fast thanks to forces outside our control won't help anyone.

But before we embark on this seemingly impossible task, physicians will first need to ask themselves a very important question, one that strikes to the very core of being a doctor: will we dare to speak up as advocates for our patients and as advocates for each other as doctors, or will we just become a talking head?

Given what's transpired to our health care system so far, I'm not sure I really know the answer.

-Wes

When We Conflate Health Care With Medical Care

From Marilyn M. Singleton, M.D., J.D.:

“Politics is the art of looking for trouble, finding it everywhere, diagnosing it incorrectly, and applying all the wrong remedies.” -Groucho Marx

The politics of selling the Affordable Care Act (ACA) focuses on promising health and wellness. Somehow, having “coverage” is supposed to get you to a primary care doctor, who will keep you healthy. And if he doesn’t, he will be held accountable by not being paid.

The fact is that “healthcare reform” is not going to cure America’s health problems.

Physicians, think tanks, and politicians are pointing out a myriad of problems with ACA. But most of them miss the main point, which starts with calling it “healthcare reform.” The term, and the conversation about it, conflates health care and medical care. But they are not the same thing. Individuals are in charge of their own health care. Physicians provide medical care to those who become sick.

(Read the rest, especially the comments)

As I and others see the problems with "wellness initiatives" promoted by politicians and the insurance industry as cornerstones of our efforts to cut costs in our medical system, we should consider if institutional financial incentives will thwart any effort to achieve cost savings as physician productivity quotas are increasingly turned to as the driving force de rigueur for hospital profitability. Unfortunately, physicians are losing their ability to be stretched much further, especially as they struggle to keep up with the mushrooming number of inefficient certification and data-entry requirements, flooded e-mail in-boxes, and coding requirements necessary to continue practicing medicine in our new "reform" era. Then add the increasingly frequent hassles doctors are experiencing with their patients' insurance claim denials that go on for months. Medical care suffers as a result. Even our frontline force for quality medical care, nurses, are being stretched thin as many of their ranks are either let go or recruited as cleaning crews on top of their other patient care responsibilities.

Meanwhile, the insurance companies are recording record profits as Americans pay more and more into our system.

But, hey, thanks to the Electronic Medical Record and health care "reform" it sure is easy to order another colonoscopy in the name of "wellness" and "health care," right?

-Wes

How to Quell Physician Discontent with EMRs

How do you quell physician discontent with Electronic Medical Records (EMRs)?

Easy.

Have the leadership of your physician organization interview the National Coordinator for Health Information Technology, then make sure your physicians read the spin.  This is one of my favorite excerpts:

Q: Many physicians are not seeing the expected financial return on investment after EHR implementation. Why is that?

A: How you implement the technology has a lot to do with the results you achieve. (ed: Now, note how he dodges the question) But the bigger issue is how the compensation system is designed. If physicians are operating in a fee-for-service environment, then many of the gains of EHRs -- for instance, in quality, safety and patient engagement -- aren't reflected in revenue. Physicians are doing more work and delivering better care and service, but the added value is not reflected in the reimbursement. (ed: Okay, that's what we said: we're seeing lower pay, not higher, despite doing more and more meaningless data entry work with EHRs.  We are often not finding return on our investment with the additional work.  Why are you now addressing nebulous issues with physician payment reform? Could you stick with the question, please?)

We've been an advocate for making sure that when value is added, it's reflected in increased physician reimbursement whether it's through the patient-centered medical home (PCMH) setting (ed: Alas: no. It is impossible for the Coordinator to stick to the question.  Now we're on to Value-Based Purchasing. WTF?  Doctors aren't PURCHASING value, dammit, we're providing CARE!), value-based purchasing or part of an accountable care structure. That's where the ability to manage information -- not just for individual patients but for populations (ed: Remember dear doctor, it's not about you and your patient, EHRs are about the population manipulation!  Huh?)-- becomes an absolute necessity, because in those models, it's not a question of whether there's a return on investment with electronic health records. (ed: Yes, dear Coordinator, in case you forgot, this WAS the original question)  A physician can't function in those models without an EHR. (ed: Really?  Since when?)

If you can stomach more, go on over and read the whole thing.  (And consider leaving them a comment about how you really feel about this spin).

There.  You're a believer in in all things EMR now, right?

Doctor?

Doctor?

-Wes

Cost Savings from EMRs: A Path to Salvation

The Electronic Medical Record (EMR)'s promised contribution to health care cost savings got a second look recently, and the results were poor at best.  But what I found interesting was the "second look" was from the same organization that did the first look: the corporately-funded, non-profit think-tank called the RAND Corporation.  From their second and more recent report:

"A team of RAND Corporation researchers projected in 2005 that rapid adoption of health information technology (IT) could save the United States more than $81 billion annually. Seven years later the empirical data on the technology’s impact on health care efficiency and safety are mixed, and annual health care expenditures in the United States have grown by $800 billion."

Who would have thought that such a prestigious organization like the RAND Corportation could have made such a teeny, tiny multi-billion dollar mistake? After all, their 2005 study was funded entirely by several of the major EMR manufacturers who have reaped billions in revenue on EMR sales since.  Is there any wonder that now the same RAND Corporation felt that the EMRs the lack of cost savings is really the end-users' fault?

"In our view, the disappointing performance of health IT to date can be largely attributed to several factors: sluggish adoption of health IT systems, coupled with the choice of systems that are neither interoperable nor easy to use; and the failure of health care providers and institutions to reengineer care processes to reap the full benefits of health IT."

What a shallow assessment.  There is no mention of the cost of these systems, their maintenance, lack of interoperability, poor user-interfaces, and in many cases, lack of graphics support.  Even more ironic, there was no consideration that someone might actually figure out a way to efficienctly skirt the government's arcaine documenttion requirements for reimbursement that would permit MORE health care spending.  No, those assessments would have been too obvious.  Instead, the Rand Corporation tells us that there were no cost savings with the EMRs is because doctor- and hosptial-customers didn't re-engineered their care processes or "adopt" substandard first-generation systems.

Give me a break.  At least the Congressional Budget Office saw through the Rand Corporation's ruse in their scathing report (pdf) from 2008.

Even so, at this point it doesn't matter.  Doctors and patients alike understand that there was too much corporate money involved and too many politicians' campaigns happily funded as the Stimulus Bill that implemented the EMR nationwide was crafted.  As a consequence, little will be done about either of the Rand Corporation's erroneous and over-zealous EMR cost-saving predictions now.  Whether we love it or hate it, the Electronic Medical Record is here to stay.   Government incentives have made it so and are still slated to grow.  More to the point, our lack-of-cost-savings epiphany came so late that most of our newly-graduated doctors have never used a paper chart and likely never will.

So now that the whole EMR implementation and cost charade has been exposed (and a blind eye permanently cast), what should doctors do now?

First, doctors must demand value for the money wasted spent on the multitude of EMR systems out there.   No where would that value be more evident than if interoperability standards were required within two years, especially when different health care systems use the same EMR system.  This is especially so with EPIC Systems, the largest EMR nationwide that is thought to contain patient records, at last estimate, some 40% of the nation's hospitalized patients.  Right now, this minute, most of the major medical centers in Chicago use EPIC.  There is simply no excuse any longer that doctors from one major medical institution shouldn't be able to view clinical records at another institution, especially when they use the same software.  Silo-ed patient data is not a value-driven proposition for the patient but rather a profit-driven proposition for hospitals.  As such, transferability of patient data between hospitals and health care systems should become one of the highest "quality standards" for hospitals to achieve and (perhaps) stiff payment penalties applied if this goal is not met. Patients (and the doctors trying to care for them) deserve nothing less.

Second, open avenues of communicating concerns about EMR functionality and safety should be mandated  and not restricted to conversations moderated behind secured web-based firewalls hosted by twenty-something computer nerds with no clinical experience.  Social media involvement by companies, be it by way of blogs, Twitter, LinkedIn, or Facebook, should be the norm.  Such open discussions encourages constructive, transparent and understandable transmission of tips, tricks, and (most importantly) needed improvements as EMRs mature.  After all, there's nothing better than a screenshot or picture(s) (devoid of patient information, of course) published for all to see to make a point and affect change. A grass-roots critique of EMR systems by doctors is long overdue.

Third, EMRs should not try to be all-encompassing.  They should stick with what they know.  Do not try to be a graphical user interface when you write in MUMPS, for instance. It's embarrassing.  If you can't do graphics, pictures or difficult multi-layercalendars, then dove-tail with someone who can.   To do otherwise creates unfamiliar non-standardized interfaces that invite treatment errors and inefficiencies rather then correcting them.

Today the sad reality is this: EMR interactions consume more of the physician's time than direct patient care.   EMR companies should realize that as long as doctors are challenged by data entry and the ever-increasing documentation and verification requirements to maintain their livelihood, they will speak out on the new challenges posed by the the EMR publically.  Companies that embrace and respond effectively to constructive criticism openly and honestly are much more likely to be viewed favorably by the health care marketplace and (who knows?) might even help to save a buck some day.

-Wes

UpToDate for EMRs

It's Friday. I sat down to work, saw this, and it made me smile:

It's not easy keeping up with technology when things move so fast.

-Wes

Data Security: A Rising Problem for Electronic Health Records

It was kind of funny reading this recent article from the New York Times that focuses on a relatively small health data breach from Stanford Hospital's emergency room:

A medical privacy breach involving Stanford Hospital in Palo Alto, Calif., led to the public posting of data for 20,000 emergency room patients, including names and diagnosis codes, on a commercial Web site for nearly a year, the hospital has confirmed.

Since discovering the breach last month, the hospital has been investigating how a detailed spreadsheet made its way from one of its vendors, a billing contractor identified as Multi-Specialty Collection Services, to a Web site called Student of Fortune, which allows students to solicit paid assistance with their schoolwork.

Gary Migdol, a spokesman for Stanford Hospital and Clinics, said the spreadsheet first appeared on the site on Sept. 9, 2010, as an attachment to a question about how to convert the data into a bar graph.

Although medical security breaches are not uncommon, the Stanford breach was notable for the length of time that the data remained publicly available without detection.

"Medical security breaches are not uncommon" is an understatement. According to the Department of Health and Human Services, 5,408,977 people have had their medical data lost or stolen, so an article that cries foul of 0.37% of this 2010 total seems fairly trivial. Worse, the reported trend is rising.

The real question that should be asked is this: What is the Department of Health and Human Services going to do about all of these data breaches? They seem to be intent on assuring us they're doing a good job enforcing these breaches, but we have to wonder.

So far, it seems they really can't do much to stem the tide: there are just too many people with computers claiming a "need to know" that have access to patients' private health data.

-Wes

Addendum: Make that 7.9 million records breached since 2009. (h/t: PDara, MD via Twitter)

Related: KevinMD blog: Your medical information is not private, and it's sold routinely.

The First Health Care Information Technology Help Desk

For anyone who has or will be implementing an Electronic Medical Record, here's the very first successful implementation of the information technology help desk:



Look familiar?

-Wes