“Meaningless Use” Stage 3 To Disappear?

In the article AHA to President-elect Trump: Cancel Stage 3 Meaningful Use, the American Hospital Association make a plea for the elimination of meaningful use Stage 3. AHA calls for focus on EHR interoperability, interoperable health IT infrastructure instead of demonstrations of certified EHR technology use.

 

The unstainable regulatory burden which includes MACRA (Medicare Access and CHIP Reauthorization Act) is unrelenting and cost ineffective.  Reading this article will help providers understand what they may be facing with the coming confusion of MACRA.

[MACRA = Medicare Access and CHIP Reauthorization Act, a 2,400 page rule which establishes new ways to pay for physician services to Medicare beneficiaries, and will be likely extended to all insurers as well. MACRA reimbursement will be based (in theory) on quality, resource use, clinical practice improvement, and meaningful use of certified EHR technology.  Ever heard the term “Meaningful Use” before?) This includes an effort to base payments on outcomes. Of course outcomes require measures to be assessed.  Payment changes are scheduled for 2019]
The AHA makes multiple recommendations that are favorable to hospitals but not necessarily providers that make reasonable sense.






“Advance health IT by supporting the adoption of interoperable EHRs, promoting a more consistent use of IT standards and providing improved testing, certification, and transparency about vendor products.”

Bottom line is that all the billions of dollars spent on meaningful use to capture endless data points that have little value to the average practitioner, this has created significant burden to cause acute on chronic “burnout” leading to chronic dissatisfaction.
The money spent could have been used on a robust national database that would have been the basis for Electronic Health Records interoperability. This would have included a national computerized order system that ended the hours relearning multiple systems.

From an EHR provider point of view, these rules have squelched creativity, efficiency, and what should have been a positive clinical adjunct into minefield of clicks and workarounds. When one adds the various meaningful use rules to the EH R, it significantly damages the EH R usability experience. While the Electronic Medical Record with artificial intelligence will hopefully someday be looked at as an asset, the barrier that interoperability imposes has yet to be solved. Why? 





Currently it is not in the interest of any EHR vendor to make their system interoperable.  Why should they allow a small (quite inventive and easy to use) system work well with theirs?  The large enterprise-level vendors have long suppressed interoperability efforts, while the smaller, creative ones, and have pushed for it. Such activity is not uncommon in the tech world.  Roku was once a small company too, and look how they have impacted the cable companies. But interoperability suppression is in no way appropriate in health care.

 

 

Improving Quality with the Use of the Electronic Health Record

The following is part of a series covering the various aspects of the Electronic Health Record to improve patient care, quality, and satisfaction.

First in the series is CPOE (computerized provider order entry). The intended goal of CPOE was to provide a digital platform for entering and fulfilling physician orders, so that the streaming real-time data could be tested for errors.  The hope has been that common errors in the delivery of medical care could be picked up and addressed before dire consequences ensued. There are myriad examples but some that often bubble to the top include faulty transcription, suboptimal medication and test selection, drug-drug interactions, and inattention to allergies and other known risks individual patients report.  CPOE theoretically provides a milieu in which the order scheme being entered is tested against protocols for the same condition and against common but serious life threatening conditions that may arise. Wikipedia states:

Computerized Physician Order Entry (CPOE), sometimes referred to as Computerized Provider Order Entry or Computerized Provider Order Management (CPOM), is a process of electronic entry of medical practitioner instructions for the treatment of patients. Basically this acronym is a tautology, as order entry always requires some computerized facility.

[Not always, but most always.  There are still places that enter and submit orders on paper; some places still use tube transport systems.


Generally, the entered orders are communicated over a computer network to the medical staff or to the departments (pharmacy, laboratory, or radiology) responsible for fulfilling the order. CPOE decreases delay in

·         order distribution,

·         resource allocation,

·         order completion,

And shall

              ·         reduce errors related to handwriting or transcription,

·         allow order entry at the point of care or off-site,

·         provide error-checking for duplicate or incorrect doses or tests, and

·         simplify inventory and posting of charges.

As one can see CPOE was basically designed like a high-level accounting tool that to improve patient care through efficiency and error reduction. But…. the “devil’s in the details.”

From a provider point of view the following achievements would be great….

1.     Reduction in illegibility

2.     No more dosing errors,

3.     Selecting the right treatment plan.

4.     Selecting the most cost-effective treatment plan without sacrificing quality

5.     Protocols that are “state of the art” by evidence-based medicine.

6.     Warnings when a mistake or allergy is perceived.

7.     Guidance by artificial intelligence to make better decisions

Problems arise, and the following phrases might be heard:.

1.     Why does a provider (me) have to do data input?

2.     That’s the eighth warning alert this hour!!

3.     How do I change an order?

4.     Wasn’t that protocol changed last week?

5.     I can’t figure out the pediatric dose calculator without my slide-rule. I give up.

6.     Why are cancer protocols mixed in with the Emergency Department protocols?

7.     My favorites list is so long, that I seem to have everything I never use on it.

8.     How do I change a med on a protocol?

9.     How do I know that anyone saw this order without a verbal reminder?

10.   What is the average time delay between the STAT ORDER and it being followed?

11.   Do I really need to write a prescription to give 1 dose of medicine in the department?

The potential positives are obvious. Indeed, CPOE would be dramatically improved if

1.     Order entry was body-zone specific

2.     Order entry was specialty specific (system specific would do)

3.     The barrage of warnings and alerts was controlled

4.     CPOEs avoided lock-step control of the ordering physician, allowing flexibility

5.     Was streamlined, user-friendly, and therefore was not so time consuming.

6.     Permitted parallel artificial intelligence, curb-side opinions to cover your back.

7.     Standard user interfaces, so you’d would only have to learn CPOE once

8.     Showed cost estimates for each order

9.     Had available lists of indications for ordered tests and treatments?

10.            So truly user-friendly that assistants were never assigned to enter orders.

Perhaps in the distant future, after countless missteps and funding fiascos these features will be available.

Meaningful Use- Rise of the “Best of Breed”?????

Is the “Meaningful Use” financial incentive actually going to end? According to article CMS Promises Meaningful Use Replacement This Year significant changes in the program will be implemented in 2016 and possibly be in effect by 2019. The goal is a more “patient-centered” output and not endless data collection.

Meaning full use was defined by the government to be

1. The use of a certified EHR in a meaningful manner.
2. The electronic exchange of health information to improve quality of health care.
3. Stimulate the adoption of EHR through financial incentives for using (e.g. not let it sit in the corner) certified EHR technology for defined elements of clinical care.

After 32 Billion Dollars expenditure in incentive money, we have a dysfunctional, non-intraoperative, and user-unfriendly national conglomeration of systems that just can’t communicate with one another.  Sounds a bit like Congress, does it not? The outcome probably should not be called a system because every product is somewhat unique and the stated goal of being able to trade information between facilities (interoperability) is no closer than it was in 2004 when then-President GW Bush put the federal government into the electronic record business.

Now, CMS has reset its sights, deciding that the new goal is not to promote adoption of EHR technology, but to pay providers for (good) outcomes that result from using such systems.  This paradigm, in CMS mind, is to replace the fee-for service paradigm. Of course! Why not!  For example, someone arrives in ventricular fibrillation and you pull out all stops to try to get the heart beating synchronously again.  Shock after shock fails.  Drugs fail. Everything fails. The patient succumbs. The outcome:  well, it is no-so-good. But you do not get paid for the powerhouse effort that you are describing on the EH R record.  No.  You write that the patient was transferred to the morgue.  Hence, the outcome deserves zero reimbursement.  Certainly much less than I you had restored cardiac rhythm and transferred to the CCU, before the patient died, and then was transferred to the morgue. Make sense?  Maybe CMS will convince hospitals to keep investing in better equipment, at least so it is ready one of the CMS administrators show up in v-fib.  Or maybe they will not, and the outcome will be vfb à morgue. 

Now, how this will be done will be interesting to watch. It will be quite challenging because certain specialties provide isolated real-time care while the traditional life-long practice provides longitudinal care. For most of the latter, the patient is still present when outcome is determined. The reconciliation of these different, and somewhat competing, paradigms will be difficult to achieve.

The Electronic Health Record, so often written about in many of our prior blogs, will need to change its fundamental character.  An emphasis on creating legally defensible documents, and an emphasis on an EHR use as a billing tool, will both be expected to come in secondary to its use as a patient-centered tool.

It’ll be nice if it works.  No skeptics here, right?  Yet, the coming evolution of the EHR may present great opportunities for focused or “Best of Breed” electronic health records that handle specific medical areas of expertise. Yes, enterprise systems will continue, but they may be constructed as user specific modules (apps) to accomplish these new goals. Think of your cell phone. These systems will have to allow “plug and play” programs or specific “apps” to give the providers the necessary support to be efficient and financially successful.

Why Do Certain Electronic Health Record Installations Fail?

The article Denver Health CIO, COO quit, blame pricey Epic EHR installation, says Denver Health Medical Center (where Dr. Kamens and I trained during our early EM careers) our alma mater had considerable financial and personnel problems during their Electronic Health Record installation. As one might expect, the vendor and the hospital had different versions of what actually happened. Lots of finger-pointing ensued.

Implementation problems of this type may be caused by locally specific factors, but are not unusual throughout the EHR industry, and appear in diverse locations. Finding out (and revealing!) what those fundamental issues were would be a great help to other institutions and vendors.  Unfortunately scenarios of installation blunders are only rarely shared outside the vendor’s office, and we are left doomed to repeat history from which all could have learned.

In the old days (circa 1970’s-80’s) it was common to attend a hospital educational programs called M & M conferences. The New England Journal weekly case discussion at Mass General was a paradigm for many through which medical prowess could be advanced.  M & M stood for Morbidity and mortality. Wikipedia notes:

“M&M conferences “are traditional, recurring conferences held by medical services at academic medical centers, most large private medical and surgical practices, and other medical centers. They are usually peer reviews of mistakes occurring during the care of patients. The objectives of a well-run M&M conference are to learn from complications and errors, to modify behavior and judgment based on previous experiences, and to prevent repetition of errors leading to complications.^[1] Conferences are non-punitive and focus on the goal of improved patient care. The proceedings are generally kept confidential by law.^[2]M&M conferences occur with regular frequency, often weekly, biweekly or monthly, and highlight recent cases and identify areas of improvement for clinicians involved in the case. They are also important for identifying systems issues (e.g., outdated policies, changes in patient identification procedures, arithmetic errors, etc.) which affect patient care.^{[1][3]  “}

In the purely clinical realm, perhaps due to present liability issues, M & M’s may not be as forthright as in the past. For certain, every intern and resident dreaded to be on the podium at one of these events.  “And what were you thinking at that point, Dr. Ausgiblinken?  Today, it is likely that the extent of dread probably includes most staff, physicians, attending, and others. After all someone has to take the blame when things go south.

Knowing an implementation is coming up is a common cause for major anxiety too. Can we do anything about the fact that many doctors, nurses, other providers, and administrators shake in their boots when a new installation is on the calendar? Wouldn’t it be nice if they could be at least as relaxed and as confident as when about to have a colonoscopy? That should not be such a distant dream.  Really.  Nobody puts the clinical, IT, and administrative teams into Sims or Trendelenburg. But to look at their faces the week before the new system arrives, you wouldn’t know it. 

Could we have M & M conferences for EHR implementations, sharing analyses of the good as well as the bad?  Publically available, they could vastly improve implementations, avoid common failures, and create an important knowledge base. Such M and M reviews would be welcome tools from which to learn about what really happened and what problems could have been avoided.

One might discern whether problems encountered were:

1. Systemic
2. Caused by individuals, particular departments, or departmental relationship
3. Resulted from lack of buy-in by the providers
4. A result of insufficient training
5. Caused by Hardware and/or software issues
6. Plagued by Usability issues
7. Due to an absence of effective leadership
8. Arose from a combination of two or more of the above
9. Etc.

Data gleaned from such open discussion would certainly help all institutions and vendors. Become more effective at EH R implantation, for the overall benefit of patients, and healthcare delivery.

"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.

Loss of Common Sense

One of my favorite Meaningful Use Stage 3 requirements is Patient Engagement.  Really???  When does a doctor not have patient engagement?  In the morgue.  This is crazy because it really does not mean PATIENT-DOCTOR interaction...it means PATIENT-EHR interaction.

It is nuts.

Maybe patients should be reading the x-rays; interpreting the labs; discussing findings with consultants.  Who needs doctors anyway?

With the internet, WebMD, Wikipedia, the patient is way smarter than the doctor anyway.  Maybe what we need is a new form of self-care.  The patient can be BOTH patient and doctor  That will really cut costs.  And think of the medical-legal consequences.  The patient has a bad outcome and sues himself.  Whoever is coming up with this stuff needs psychotropic medications.

Who Owns the Data???

The battle for interoperability and easy data transfer is just beginning.  The author of Electronic Health Record vendors Take Patient Data Hostage: What Should We Do? suggests that the electronic records incentive program aka meaningful use has bee fairly successful in getting providers t adopt and EHR system.  However, the interoperability and goal of instant data sharing has not gained much traction.

The majority of EHR product vendors are unwilling to work with competitors through HL7 interfaces to solve this problem.  They charge exorbitant rates for data transfer and HL7 interfaces.

This leaves the provider with the question, "Who owns the date?".  A cynical view would say that in hierarchical order is the NSA, CMS, Google/Apple, Vendors and lastly the provider and/or patient.  In the article, several solutions are offered such as doing nothing- allow market forces to fix the problem, forcing cooperation through more legislative or administrative mandates, or continue to pay through the meaningful use program for interoperability.

When a provider wants to switch EHR vendors, the issue of data transfer comes up last.  The cost of this process inhibits the practices' desire to try something new and possibly an improvement.  It greatly discourages boutique products that are specifically designed for specific lines of business since the price to interface with balky enterprise systems is cost prohibitive for a small practice.

It will be interesting how the quest for free data belonging to the patient is resolved!

Should There Be a Continuous Medical Education Mandate for Computerized Order Entry and Meaningful Use?

MA Physicians Must Show EHR Proficiency; the State of Massachusetts now has licensure requirements the include proficiency in the user of the Electronic Health Record (EHR).  These include understanding computerized order entry (CPOE), meaningful use, and the core EHR. 

In Florida, there are core continuous medical education (CME) requirements: HIV, medical errors (risk management) and domestic violence.  Clearly, every time a new "hot problem" arises, a new CME requirement is generated.  Next will be Ebola and vaccinations (measles, flu,?).

It is not necessarily bad to make sure that everyone is up to speed on certain topics, but what topics should be selected?  A case can be made for multiple topics both general and specialty specific.

The issue with adding the EHR under the general CME umbrella is a lack of industry standards.  Knowing how to use an EHR at a specific location does not necessarily translate into competence with other EHR applications.  Workflow is characteristically site-specific, so users ma approach the software quite differently.  You would not deal with an automated CPOE interface the same at a 120,000 visit ED as you would at a 14,000 visit ED. CPOE varies from vendor to vendor as well as the workflow for using CPOE from site to site.

 It is often essential to understand the result of a right click on the mouse  on any system. How about when going from system to system?  Will you get rodent dyslexia?  Maybe!?!  For more on the right click, read my prior blog on the Right Click Dilemma!  It is noteworthy that recruitment ads for locum tenens already include the type of system in place at the practice or hospital seeking physicians.

The second piece of the puzzle is understanding meaningful use.  Understanding meaningful use?  Seriously!?!  Remember that MU is the government's attempt to promote adoption of EHRs.  It does not, and should not, directly affect patient care.  Attention to it by practices and hospitals is ordinarily to make sure they get their share of the incentive money.  Physicians are being told, "please check these boxes, so we can be paid", but unless a physician is seeking to become an informatics subspecialist, does he or she really need to know what MU is about?

The ultimate solution is establishing national standards for the operation of any EHR, including CPOE as well as patient databases.  If every system used the same fundamental database and CPOE, the provider can figure out the various approaches used by vendors.  Remember, the Massachusetts medical society backed this issue.  HL7 has been working on it for years, and has many tools to enable EHR standardization.  Why not adopt realistic standards?  That would certainly be a meaningful, and useful thing to do.

Trying to Put the "Meaning" in Meaningful Use

High noon for federal health records program? 2015 will be a critical year for testing the system is an eye opening article.  Arthur Allen gives a critical analysis of the whole dilemma regarding the value of an Electronic Health Record (EHR) based on the present financial incentives.

The article explains the motivation of institutions to digitalize medical records, which primarily are two: money (potentially lost) and fear (of future penalties for not abiding by the complex rules the government has created).

Meaningful Use Objectives are defined in the chart below:

1. Improve quality, safety, efficiency, and reduce health disparities
2. Engage patients and family
3. Improve care coordination, population and public health
4. Maintain privacy and security of patient health information

Ultimately, it is hoped that meaningful use compliance will result in:

1. Better clinical outcomes
2. Improved population health outcomes
3. Increased transparency and efficiency
4. Empowered individuals
5. Robust research data on health systems

The intent of MU is good, but the reality is very different.  For one thing, "meaningful" depends on perspective.  That is, for a clinical user, meaningful is a different animal than it is for administrators, and for CMS, meaningful is a wholly different species.  Providers want usable data that supports direct patient care; they dislike having to capture endless streams of data for clinical irrelevancies.

So let's ask the following- since the bottom line is that everyone wants better care, what does a clinician find meaningful while providing that care:

1. Easy access to all relevant data in a recognizable format
2. Advisory alerts when appropriate
3. Clinical decision support
4. CPOE (computerized order entry system) that is universal and not totally provider driven- (Where have all the ward clerks gone?)
5. Insert your own here "xxx"

The government is looking for data to make political, cost, and cultural changes.  One unintended result is a new industry, a new unregulated "profession", medical scribe and that has certainly raised costs.  Along the same lines, CPOE has led to more tests, which equals more costs.

My suggestion is to read the article.  It does an excellent job of presenting the issues.  Ultimately, the solution is to create a national medical database that is easily accessible, secure, and agnostic as well as transparent to all EHRs, regardless of vendor or format.  With this database and a standardized CPOE, major benefits will be obtained.  Through the retrospect-o-scope, one sees that money could have been spent on this first; then the hospitals and providers would have clamored to be first to get an EHR that makes life easier.  As it is now, there is quite a mess to sort out with respect to interoperability and usability.

Where Has All the Interoperability Gone?

The entire meaningful use project intended to encourage provider adoption of Electronic Health Records (EHR), with the promise of easy access to patient records with two underlying goals: 1) improve the quality of health-care and 2) control rising costs.

Interoperability represents the ability of systems and organizations to work together (inter-operate).  Due to technical constraints systems often impose, the essence of interoperability in health-care has become, in essence, the need for easy, reliable exchange of information between these systems.

The EHR was supposed to interact with other EHRs to synchronize individual's medical history including tests and treatments.  Such synchronization in the US is important, as many patients wind up in different care settings.  This synchronization would give a care taker permission to all of the patient's clinical information.  This clinical data would be stored in a Health Information Exchange (HIE).  The HIE is defined as a mobilization of health-care information electronically across organizations within a region, community or hospital system. 

Although well-intended, the meaningful use program with its billions of spent dollars has further spurred the development of multiple competing health records that are by nature proprietary.  Enterprise systems, that provide the backbone of huge hospital systems are reluctant to interface with practice specific specialty "boutique" programs.  Why should these enterprise systems enable integration with boutique programs, when monopolizing their implantation over a hospital system is immensely lucrative for a vendor?  However, the reality is the boutique systems are often focused on end-user acceptance and walk-up usability, while enterprise systems--by their very nature, and especially by their hybrid, unfocused character--are unable to satisfy all end-users, if any at all.

How hard is it to interface through the HL7 standards developed for meaningful use and HIE?  According to most experts, accepting these standards takes the willingness of the participants involved.  For business reasons, many large organizations do not support standardization, and so interoperability--a functionality fully dependent on standardization-- is not an easy task.  Even if a hospital may be willing to accept the interoperability challenge, the cost of implementation is often artificially elevated by the proprietary vendors, making it prohibitive.

A related factor, referred to above with the term "hybrid", is the fantasy of a one size fits all product.  Hospital IT departments love hybrids because they theoretically means less hassle.  Their focus is less on the end-user than on avoiding potential problems for the IT department.

Hospitals, CEOs, private practitioners, politicians, and all health-care advocates should encourage their EHR vendors to allow the concept of interoperability to be enacted upon and enhanced.  You can find more information on the subject at the Center for Medical Interoperability.

Is It Time to Start Downsizing?

The author of 12 Changes That Will Affect Doctors' income in 2015 lists major changes that should have a net negative effect on providers’ incomes due to the Affordable Care Act. I suggest you read this article.

 

1.      High deductibles is the new self-pay in disguise with many patients not aware of this serious issue.

2.      Decrease in malpractice premiums which will probably be a transient benefit. Caps are being overturned or litigated in most states.

3.      ICD-10 will begin in October and the true cost is not yet known. Most experts think practices should have a 90 day reserve fund to make payroll.

4.      Practices involved in Medicare Accountable Care Organizations will be losing their guaranteed contracts to avoid losing money. There is a bill in congress to keep the contracts viable for 3 more years. Not sure what will happen in new congress.

5.      The emergence of Telemedicine is affecting the growth of certain practices. The reimbursement for these services are still be battled over. The legal liability is also in flux.

6.      Retail clinic pharmacy driven practices are direct competition to the standard practitioner.

7.      Primary Care Physicians will lose their enhanced Medicaid payments. These payments will lower back to approximately 40 cents on the dollar.

8.      Meaningful use become more “mean” and will now penalize rather than reward the practitioner.  The government wants its money back.

9.      PQRS will no longer give maintenance of certification monies for meeting quality measures. Penalties will ensue.

10.   Medicare payments to specific providers are now available without context on new websites.  Bad publicity is the net effect.

11.   Medicare will start paying for chronic care outreach to providers who deal with patients with 2 or more chronic conditions. The downside is the necessary documentation to avoid future audit.

12.   New CPT modifiers to replace the 59 modifier for procedures. Make sure your billing team is ready to change. Failure to act will lead to another excuse to deny or delay
CLAIMS MADE.

 

Welcome to the electronic age to save Medicare money. These trends are just the beginning to try to save Medicare. Cost shifting to the provider is an easy route because they are all “rich doctors” anyway.

Monopolizing Physician Time is NOT Meaningful!

Guest blogger Dr. Donald Kamens, MD discusses the definition of meaningful use- Enjoy!

Taking Physicians away from their patients is anything but meaningful.  I saw a urologist yesterday, and while he was unable to look me in the eyes because he was fixed on the screen, he was also saying, "see, I cannot even see you, judge your reactions, assess your status...the screen takes it all away from what was once the doctor-patient relationship."

He further said, "that every day (every day!) he has to stay late to complete his MU requirements, and most often winds up taking the work home.  It is destroying his family life as well.  Patient care is being undermined.  He said that the issue was not only the MU criteria itself (which he said will have to be relaxed), but also the implementations, and was complaining about their current system- one of the big 3, but learned that most all other products have the same or worse issues.  A big (HUGE) push back is coming!

Fortunately, there are products out there that have been designed with thought of physician time, efficiency, and making clinical work easier.  Unlike some of the other products for EDs, UCs and clinics, a physician can work at a relaxed, but speedy pace without being overwhelmed by the screen.  Allowing for more time to see what is going on with the patient...

10 Things Medical Records Won't Tell You!

The Wall Street Journal published an article last week on the 10 things medical records won't tell you.  I have condensed the list, so you get the idea...

1. COST: The price tag is HUGE!
2. SHARING IMPORTANT CLINICAL INFORMATION between providers is a myth.  Even high-price tag enterprise level systems do not do this well, or cannot, especially between different hospitals and doctors.
3. DOCTORS HATE IT in general and pretty consistently, especially if forced to use it by their hospital, the government, or partners.
4. DOCTORS HAVE LESS TIME to spend with patients...because they have to fiddle with machines.
5. PRIVACY physicians may employ strangers such as scribes to manage there cumbersome EHR into the previously sacred and secure doctor-patient relationship.
6. ERRORS MAGNIFIED mistakes are easier to make; just hit the wrong key, or have a voice recognition system hear "no chest pain" instead of "known chest pain".
7. INFORMATION OVERLOAD TMI- too much information...sometimes, in fact most of the time, we just don't need or want to read "War & Peace" on every patient, and only a section of the total is needed in any clinical situation.  But the EHR commonly gives it all. No one, especially not clinicians, have the time to read it.
8. IDENTITY THEFT EHR's contain much of your demographic information--social security, payment, address, phone, work schedule, etc.  They are therefore a fertile ground for the thieves that prey on such things.
9. YOU BECOME A MARKETING STATISTIC your information will be marketed and sold e.g. to pharmaceutical companies, insurance companies, etc.
10. BIG BROTHER IS WATCHING the government can and will track the events that occur in medical interactions through EHRs.  The requirements and criteria for this sort of tracking are already in place.

Choose an Electronic Health Record that has thoroughly considered these complaints and actively deals with them.  Complaint #10- government policies and incentives is the biggest driver in turning to EHR.

Can a Physician Run a Business???

Physicians have run small businesses for years with varying degrees of success.  Success can be identified multiple ways: 1. Financial; 2. Personal Satisfaction- being a good doctor; 3. Psychologically Rewarding- ego gratification; 4. Etc.; 5. Etc.

Physicians are excellent at providing good medical care and excellent at thinking that this automatically translates into productivity, process improvement, patient satisfaction, financial reward, and efficiency.  They mold their practices, so that everything works reasonably well, according to their personal vision of how it ought to function.

With the continual addition of more rules, the Affordable Care Act, meaningful use, and higher costs of keeping practices open, many offices are closing.  Whereas, the application of some sophisticated guidance from outside consultants could help.

Physicians may consider hiring such consultants, and often their first recommendation is to create a "Business Plan" representative of the physician's, or practice's goals. Such a plan is corporate-speak for an organizational strategy to achieve those goals, and is customarily laid out on paper.  However, many doctors, if they have a structured overall plan, often maintain it solely within in their own minds, if maintained at all.

Decisions always have to be made for that plan, and therefore always evolving to keep up with the ever-changing practice environment.

Examples include:

1. What Electronic Health Record works for this practice?
2. Is the meaningful use incentive funds worth it?
3. What computers to purchase?
4. How many providers are necessary- physicians, NP, PA, medical assistants, voice activated technology?
5. Do we staff to demand- right number of people at the right time of day?
6. What malpractice to choose- my bias is the least expensive with the lowest limits of coverage acceptable-?
7. Should we perform labs and x-rays in-house or partner?
8. Should we do our own billing?
9. What about ICD 10?
10. Do we accept Medicare and/or Medicaid?
11. How do we get credentialed with payers?
12. How much do we market or advertise?
13. Do we rent, lease or purchase space?
14. Should we sell out to the hospital to eliminate 1-8- what happens after the 2- year honeymoon period?

These are complex questions with no easy answers.  Best decisions in this regard are always made when time is taken to get sufficient data and advice before making adjustments.  But even if decisions are made to change practices, changing behaviors is not so easy, no matter what the facts, or realities of the particular care setting say.

Wisdom is not always easily acquired, and one should carefully listen to those both within and outside of the particular workplace in question.  Optimizing one's practice through small incremental steps with limited investments can be richly rewarding.