Monday, July 13, 2015

Would You Consider Joining Local 911?

In the interesting blog Physicians must unionize.  Here’s why, the author recommends that physicians create a union to protect their interests from governments, health systems, and the endless prevailing forces that the individual has no control over.
I would suggest reading the article as maybe the time has come for physicians to get organized and protect their substantial interests.

These interests include autonomy, financial security, work conditions, and protecting the greatest guild ever created. Physicians have reaped the benefits since the 1960’s thanks to a fee for service model and Medicare guaranteeing a financial floor to generate exceptional incomes for 30-40 year careers. Along with social status and respect, it is a great job.
However, practice and personal satisfaction has significantly decreased in the last decade. More government mandates (usually unfunded), hospitals employing physicians, and the destruction of the personal doctor-patient relationship has been steadily on the rise.

Physicians are generally organized if at all by specialty societies with varied interests. This diminishes the overall power and clout of all physicians. Critics would argue that doctors are overpaid compared to the world market and are chief offenders at driving up costs.
A similar argument can made against the National Football League Players Association (NFLPA). It has been called a joke because it represents rich football players. The football players do make great sums of money but their careers last 3-5 years with lifetime physical disabilities to follow.  Physicians can earn significant amounts of money over 30-35 years without similar threat to life or limb.

The union could  represent the physician body in the ongoing financial negotiations with CMS, insurance companies and hospitals, work rules, malpractice, contracts, Electronic Health Record implementations, ICD -10 implementation, and etc.
The individual has lost any clout to fight these forces or influence the decision making. A physicians’ union would put the “players” back in the discussion. And yet, there may be ethical and practical considerations that might keep some from wanting to join a union.  For example, would you cross a picket line to help the bleeding patient on the sidewalk?  Most would say yes, despite getting roughed up or jettisoned from the union.  And then, how many times have you seen a hundred or more physicians in a meeting (think union meeting) that agree on anything?  Younger physicians steer clear of medical entities, such as the AMA, which has a pre-union character to it.  Perhaps they realize that the results of joining could include an early retirement a la Jimmy Hoffa.  Lots to think about before unionizing.

Monday, July 6, 2015

"Hindsight is Always 2020. Ask My Dog"

After reading and digesting the article What Will EHRs Look Like in 2020?, my partner Don Kamens, MD had some insight to share- Enjoy!
When a physician practicing 15 years from now (2030) looks back one decade (to 2020) will he or she see a quantum leap in usability and functionality from our current time?  Certainly, in the decade 2005 to 2015, the leap has not been quantum, but impaired.  Impaired by such encumbrances as MU (meaningful use) and similar constraints that require caregivers to work with keyboards and mouse, rather than with patients. 

Interestingly MU is also the answer to a famous Zen koan that means "nothing, nothingness, or not at all." It applies in the EHR realm too. In Zen, the question that yields MU, "Does a dog have the essence of Buddha?" contains about as much meaning as meaningful use in the EHR realm. None. Ask my dog, he will tell you. Or he will bark at you.

EHRs bark at physicians too.  Ask the users.  As one punster said, "it's a ruff situation." Indeed, after a particularly trying shift, most ED docs would rather be wresting with the pit bull who bit the patient in room 14, than with the EHR to complete notes, and get home.  Many would choose the dog as an easier path .  

It is also interesting that a section in the JAMIA article is headed Billing Requirements Now Drive Much of Documentation.  Now?  Billing requirements have been driving documentation since well before the advent of EHRs, as they are now known.  Indeed, "justification of evaluation and management codes" has been with us for many, many pre-silicon decades. The difference now is that these justifications are now viewed as electronic data, rather than as marks or notes on paper.  But the information is not substantively different at all; it is identical, just gathered and assembled differently, and more transferable, interoperable. Severing the calcified link between a physician's account of clinical work done and payment received will need  surgical intervention. Many are pushing for outcome-based reimbursement schemes. But few physicians want to see outcome-based payment systems, as those with poor outcomes sometimes require the most work.  

What is missed in this analysis, is that the EHR in 2020, when looked at with 20-20 hindsight, should not repeat the mistakes of the past.  But it will.  It will because the perspective of guidance in this realm is incorrect, and far too quantitatively based.  Medicine has quantitative aspects, but it is far from a quantitative science. It is largely qualitative, and heavily subjective. 

What is the fundamental mistake that has been repeatedly made with EHRs that will perpetuate the sins of the past?  Well, one would hope that in 5 years, approaching the EHR on a case would be greeted with a sigh of relief, rather than with the trepidation of taking the first step from basecamp to climb Everest.   EHR developers should be using the experience of video games, Roku's, automobile driver interfaces, Khan Academy, from (yes) smartphones and cool apps.  It's not happening at the moment.  And it is not happening particularly because of the constraints that MU and related rules put on the system.  

Ask any Zen adept. Emptiness ! MU is nothing. Or ask any ED doc forced to use an EHR that drives him or her nuts.  Or ask my dog.