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.

Scientific Basis of "OM"

The power of meditation is explained quite well in the article, From OM to OMG: Science, Your Brain, and the Productive Powers of Meditation.  It analyzed the brain by MRI scan that is meditating to the normal active brain.  She claims it leads to better focus, less anxiety, more compassion, more creativity, better memory, less stress, and more grey matter.  The aging population especially myself can use all of these.

Meditation turns off the tumultuous, endless thoughts produced by the brain allowing one to focus with mindfulness on nothing or a particular pathway.  OM or any mantra is a sacred utterance, numinous sound, or a syllable, word, phonemes, or group of words believed by some to have psychological an spiritual power is a vehicle to achieve a meditative state.  OM is the vibration of the universe- more than a sound, but the vibration.  What's the bottom line for most people who are skeptics?  The benefits outweigh the negatives of trying it.  What if it really works?  Take advantage of easy solutions to complex problems.

This is all well and good for those who wish to spend time in a cross-legged position, or chanting, or meditating on koans, but one would eventually be led to ask, "What is brain anyway?".  What is mind?  As the Zen adept will note: if you understand, well then, things are as they are.  And if you do not understand guess what?  Things still are as they are.  Quite likely the brain exists in the physical universe very much like a smart phone on a plan; the data probably exists in multiple dimensions, and as the phone works and the brain has not stroked out, the information is there.  But does it matter that we get it?  Indeed when asked to walk the dog one should first reflect on the hope that someone's karma does not run over your dogma.

Using Shared Decision Making as a Tool

Shared decision-making is an approach where clinicians and patients communicate together using the best available evidence when faced with the task of making decisions.  This is ne of the new trends allowing patients to directly participate in their care.  The goal is to give the patient sufficient data to make an informed decision with the clinician to determine the curse of their medical care.

In the article, What is Shared Decision Making?, the author defines as a collaborative process that allows patients and their providers to make health care decisions together, taking into account the best scientific evidence available, as well as the patient's values and preferences.

Traditionally medical care was 100% paternalistic, where Dr. Welby knew what was best in all situations.  With the tremendous growth of information available the consumer can google all the information they may or may not understand.  Even if they understand, they do not necessarily have the context to make appropriate decisions.

The provider is the person who adds the context, but it is easy for the provider to bias the process.

There are certain situations in medicine where shared decision making is inappropriate.  A patient who needs life-saving surgery or immediate cardiac care should not create an excessive dialogue.  Other not so urgent problems with multiple treatment options is another story.

There is one place where shared decision making can be used as a tool to eliminate medical-legal testing, CYA procedure, unnecessary hospitalizations, and the overuse of our extension and expensive pharmacopeia.  This will also appeal to practitioners who believe in the motto, "Trust Me" and/or "In My Experience".

Keep in mind that any action has risks.  While one might wish that the benefits of an action outweigh the risks, we all know this not to be consistently the case.  Thus any decision on which an action or the act of inaction is based has risks, and a risk/benefit ratio can be surmised.  Actualized risks have costs, the most central of which are risks to the patient and the patient's health, the secondary, and tertiary, tiers of actualized risks are litigation, blame, and social or interpersonal dispute regarding responsibility for the decision.  In traditional care models, the physician bears the secondary levels of risk; indeed in Marcus' time there was little litigation, and the risk of a questionable decision was small.  But in our current dominant medical model, there is considerable risk to the care of patients, and to shouldering the decision making process.  Hence, medical care is expensive.  Broad shoulders require huge payouts and large premiums.

In a share decision model, who would bear the risk?  Would it too be shared?  Or perhaps when the patient is a decision maker, he/she agrees to assume all the risk of the decision.  How would the elements of a negligence claim be parsed?  Duty, Breach of Duty, Proximate Cause, Damages.  Shared decision-making may be an advance, but some pieces have to be in place.  For example, standard forms upon which a doctor checks off the options, risk, recommendations, and the patient perhaps on the other side of the sheet notes his acceptance, decisions, and signature.  More forms, that's for sure.  Lots more forms.

Take advantage of the consumers' willingness to participate in their care by having informed discussion with them.  Talk with them like a family member, and give them the same advice.  The monetary savings will be astronomical and your public relation scores will sky-rocket.

A Technique for "Road Rage"

Road Rage an aggressive or angry behavior by a driver of an automobile or other road vehicle.  These behaviors could include rude gestures, verbal insults, deliberately driving in an unsafe or threatening manner or making threats.  Road rage can lead to altercations, assaults, and collisions that result in injury or even death.

A simple technique to combat road rage or any stress is Pranayama breathing.  Pranayama is a Sanskrit word meaning extension of the prana or breath- extension of the life force.  It is a yogic discipline with origins in ancient India.

A simple form of this breathing is a long 3 second inhale through the nose followed by a long 3 second exhale through the nose.  Easier said than done.

One of my yoga instructors stated that in 12 seconds- 2 complete breath cycles- one can eliminate stress and hostility.

The next time somebody cuts you off in your car, try 1 breath I, 1 breath out, 1 breath in, and 1 breath out.  You will be surprised by the power of the breath!

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.

Fighting the Most Common Chronic Financial Illness

Chronic illness is a long-lasting condition that can be controlled but not cured. As described by the Centers for Disease Control, chronic disease is the leading cause of death and disability in the United States.

In financial terms the most common chronic illness is the “Disease of Fixed Expenses”. This affects all demographics and incomes. It is the never ending list of payments and obligations that one accrues through ordinary life. It becomes an acute illness when the “patient” gets ill, fired, laid-off, and or retires where the monthly income is significantly reduced or eliminated.

This can be controlled through conscientious budgeting, but this is not in the nature of 95% of the population. The advice is always the same- Save, spend less, avoid immediate gratification, have a plan, etc., etc.

This advice is always in a vacuum that doesn’t take into account the pressures to spend by family and friends is endless. The most organized and frugal person may not control their dependent group leading to a feeling of hopelessness or just “going with the flow”.

Some easy suggestions to ameliorate the problems.

1.      Anticipate that house payments, car payments, insurance payments, and tax payments never go away.  Realize that the most expensive house and or car is not necessary and these possessions are only tools. After a couple of years, the $25-40,000 car gets you to the same location as the $60,000 vehicle. The more expensive car with insurance, maintenance et al costs over $1,000 per month for 5 years.

2.     Discuss money with your family/dependents and carefully explain “how much a broom” costs and come up with a reasonable spending approach. Let them make compromises to get what they want.

3.     Realize you are getting older, and basing your “happiness” on things is misguided and driven by television and movies.

4.     Avoid being jealous of another’s success.

5.     Stay healthy and avoid medical costs.

6.     Anticipate unanticipated disasters – things are going to happen; face it. These characteristically require significant expenditure, often all at once, and often without time to develop a less costly strategy. Thus, planning for, and having an account with, say, $100-$150K, set aside only for emergency purposes, is wise.  If you do, there are several principles: don’t touch it for anything but an emergency; never borrow from it thinking you will repay (shortly) in the future. You won’t. Are you wise?

 

These may sound preachy but I am guilty of all these sins and now realize the shortsighted of my lifestyle decisions.

Making more money does not improve the condition, it only changes the paradigm. More money=More expenses=More Fixed expenses.

 

"Melting" Your Aches and Pains Away

My spouse recently started a new program called the "Melt Method" to achieve flexibility, relaxation and pain relief.

The self-treatment system claims to restore the supportiveness of the body's connective tissue to eliminate chronic pain, improve performance, and decrease the accumulated stress caused by repetitive postures and movement of everyday living.

Benefits include:

Improves

• flexibility & mobility
• posture
• results of exercise
• range of motion
• sleep & digestion
• overall well-being

Reduces:

• aches & pains
• wrinkles & cellulite
• tension
• headaches
• risk of injury

Does it work in real-life?  It essentially functions a directed self-massage techniques that involves using soft rollers, acupressure-type balls for hands and feet, and stress reduction attempting to improve one's general well-being.

My wife and friends claim they are 1-2 inches taller and stand up straight after a standard class.  Wanting to take a peaceful nap after the sessions is a side effect.

As one ages; stiffness pain, loss of flexibility, balance, and loss of range of motion become the reality instead of the exception.

At present my wife is involved in Yoga, TRX and the Melt Method and the combined results are pretty outstanding.  My suggestion is you might add this to your regimen.  It is a great substitute to using medications to treat chronic pain.

I recently went to a James Taylor concert and the crowd looked like (myself included) an AARP convention.  The majority could have used a physical and mental health program to walk up on down those steep stairs.