Thursday, April 29, 2010

Military Medicine Funding for Regional Extension Center

Continuing this week's summary news Better Health created a series of video interviews at HIMSS.  You will find it here. Thanks to Val Jones, MD and Dr. Anonymous.  The range of interviewees extends from Sprint to Epocrates.

Increases in Health-Care Costs Even Worse in Military

The military’s latest enemy: rising health-care costs.

The Governor's Healthcare IT Conference

How Smartphones are Changing Healthcare for Physicians and Providers


New Regional Extension Centers Might Lack Proper Funding, Staff

from today's iHealthbeat:

Regional extension centers might be too understaffed and underfunded to provide the help health care providers need in adopting electronic health record systems, according to a recent study in the journal Health Affairs, American Medical News reports.

The 2009 federal stimulus package includes about $640 million to establish regional extension centers to help small health care practices become meaningful users of health IT.

HHS has awarded funding to establish a total of 60 centers throughout the U.S.

Study Findings

The study, funded by the Commonwealth Foundation, reviewed 29 existing programs that aim to help health providers with EHR adoption.

The study authors concluded that those working at the extension centers should have direct experience with small practices and technical knowledge -- a combination they say is difficult to find.

The researchers noted that many health care practices have difficulty selecting an EHR system and that extension centers are not providing adequate assistance in that area.

Researchers also warned that regional extension centers might be unsustainable due to inadequate funding. They noted that similar projects in Massachusetts and New York spent on average 10 times as much per targeted physician than the stimulus package funding provides (Lewis Dolan, American Medical News, 4/28).

Is  it possible that this will be an unfunded mandate?  Will state governments or university systems have to foot the rest of the bill, and will they?  Certainly this may fuel a new wave of employees, but who will pay them?  The 40,000 dollar incentive per physcian says nothing about the cost of selection, implementation, or operational and maintenace costs.

Nouns or Verbs??

The infusion of information technology is not unique to health care. Technology is not a standalone black box sitting in the corner of the office or in a closet.  Those in the technology industry are now recognizing the importance of integration and to bring 'game changing ideas' to the market place.

Is technology a noun or a verb?  I think you will find this speech by Anish Chopra, the Chief Technology Officer for the United States. interesting.


Does eHealth technology such as email lighten the burden for physicians or does it impose additional responsibility upon them whether they are reimbursed or not?


A study published in the New England Journal reveals this counterintuitive finding. Simple is as simple does; More time on EMR or EHR, less time with patients, not the reverse.  Tell that one to the policy makers.  Okay I can spend an additional 90 minutes a day filling in the boxes and checking off the drop down menus and see 6 or 7 fewer patients.  That will really increase the shortage of PCPs.  And what about the  nonsense of coding for email and telephone calls.  Please, how is

the nation going to pay for that, not that MDs do not deserve to be reimbursed for their time.

The leaders of our government have a very strange thought process, or they are liars and have a hidden agenda.


And now something we as MDs have always realized, the not so hidden cost of sending a bill to the patient and the payor.

Another study performed at the Massachussetts General Hospital and published in Health Affairs (abstract(full pdf article), explains how  " The U.S. system of billing third parties for health care services is complex, expensive, and inefficient. Physicians end up using nearly 12 percent of their net patient service revenue to cover the costs of excessive administrative complexity"


Table 1:   Financial Cost of Administrative Complexity

Table 2:  

Administrative Complexity Burden In A Physician Organization’s Professional Billing Office



Saturday, April 24, 2010

Meaningful Use, ONCHIT

Today's  offering is a collection of web reference sources, and video keynotes regarding the Office of The National Coordinator for Information Technology.



Electronic Health Records Critical to Effective Reporting of Quality Measures Says ACP


David Blumenthal MD on Meaningful Use of EMR. Dr. Blumenthal is the National Coordinator for Health Information Technology His Keynote Speech is 20 minutes into the video.


A Parallel Universe  David Hesse, CEO Sprint/Nextel

Dramatic Challenges and Changes in Health Communications

Mobility Technology and it's use at the Point of Care

Compelling Health Information Solutions

4G, What's in it for me?


There is much buried in this legislation....a worthwile  read, even if only a quick scan

Competition for Certification Authority




????  During the last four years EHR vendors have formed the alliance called CCHIT, to establish the standards for interoperability of disparate electronic health records.   A large number of vendors have already complied with this standard.  In fact many potential users have taken a wait and see attitude because of the lack of a standard.

ONCHIT had recently announced that it would seek out other potential certifying bodys (ie, COMPETITORS) before adopting one standard.  Thus far there has been only one other competitor (THE DRUMMOND GROUP).

Friday, April 23, 2010

Growth and Consolidation of the EMR Industry


The passage of the ARRA and HITECH Act creates a mandate of 19 billion dollars to the health IT industry.  This creates fierce competiton amongst HIT vendors for these dollars.  Mandates are not the same as actual funding.  We see this in many other situations.  Let's hope the government will be capable of following through on the congressional mandate.  It's a bit like California's situation, or the year end delayed or non payment of medicaid bills each year. The government  is free to back out of mandates from congress unless all hell breaks loose.

Vendors will be quick to offer their solutions, even if deficient, inefficient for physicians to implement and use.  Feedback from physicians remains critical, otherwise solutions will remain stagnant if they can continue to market and sell poor software. There will be no driving force to improve with research and development.

Physicians and hospitals must vote with their pocketbooks, rather than aceeding to government mandate to 'buy something' whether it suits our needs  or not. In my opinion if caution and deliberation are bypassed much of the investment will be a total waste.  The time frame for implementation fits someone elses needs not that of the health care industry.


Austin Merritt points out the current state of affairs amongst the software companies .

  • NextGen – One of the “biggest names” in EHRs, NextGen focuses on medium to large enterprises. However, its system is certainly able to scale down to smaller practices. While it is often too expensive for groups with less than ten physicians, it has a strong position in the sweet spot of the market. Its .Net-based system is sold both directly and through a channel network, so NextGen is a good fit for Microsoft.
  • GreenWay – GreenWay has a nice product, but is toward the smaller end of the companies on this list. It sells primarily directly and has some channel partners. PrimeSuite 2008, its EHR and practice management sytem, is .Net-based and is popular among small and mid-sized groups. Microsoft could leverage its resources and Greenway’s technology to become a major force in the industry. Moreover, Greenway doesn’t come with any legacy of old architecture or acquired customers.
  • Pulse – Pulse has quickly climbed its way into the ranks of bigger EHR vendors and will likely stay here for some time. They were one of the first vendors to achieve 2011 CCHIT certification and are receiving a lot of buzz as a result. While the system is scalable and .Net based, Microsoft would likely want to pursue bigger fish for now.
  • Aprima – Aprima (formerly known as iMedica) has focused on its .Net framework and N-tier architecture from the beginning. As a result, its modern platform and interface make it widely received among physicians across a broad range of specialties. While Microsoft would likely focus on larger companies first, Aprima could be a nice additional partner to champion .Net.
  • AllScripts/Misys – A large brand and a publicly-traded company, it is a logical first place to look. After all, the company claims to have 160,000 physicians using its products. However, the 2008 merger between AllScripts and Misys presents the usual integration challenge, which might keep this firm busy for quite a while. Although we think the future of AllScripts/Misys is very promising, Microsoft probably wouldn’t get involved at this point.
  • eClinicalWorks – This system is probably the most ubiquitous of the list, especially among smaller practices. The recent deal to sell eClinicalWorks through WalMart will definitely increase its brand recognition and share of the market. However, the system is built in Java, an open programming language that is the traditional enterprise alternative to Microsoft .Net. Microsoft would most likely rather acquire a pure .Net system or one that is at least close to it, especially with Oracle, IBM and SAP all embracing Java.
  • Eclipsys – Eclipsys acquired MediNotes in 2009 in an attempt to move users to its Peak Practice EHR. While Eclipsys is fairly popular among hospitals, Peak Practice has not achieved similar success among small to mid-size outpatient practices. Existing MediNotes users are not thrilled about being forced to purchase Peak Practice and we’ve seen quite a few seeking a new solution from a new vendor. We think the success of the MediNotes deal is unclear and Microsoft would steer clear for now.
  • Athena – The youngest company on this list, Athena’s product offering is slightly different from the others. Its system is offered via software as a service (SaaS) and is combined with outsourced billing and revenue cycle management services. This offering is indeed unique, but not a suitable target for Microsoft due to its SaaS offering and labor-intensive service component.
  • Epic – This company possesses an interesting niche in the market. It has only 190 clients, but 150,000 physicians using its products. This is due to its focus on only the largest healthcare organizations in the United States. While this focus is great for Epic, it wouldn’t be effective for Microsoft. Epic will never be able to achieve the ubiquity in the small to mid-sized market where Microsoft dominates. It also sells direct, contrary to Microsoft’s traditional indirect sales mode.
  • Cerner – Cerner’s cash cow is Millenium, a product designed primarily for hospitals. PowerWorks, its outpatient EHR, does not possess the market share among physician practices that Millenium enjoys among hospitals. While Cerner is a recognized name, few practices consider PowerWorks. It is also an older system. Cerner would need to improve its PowerWorks offering before becoming a suitable target for Microsoft.
His analysis was based upon a possible acquisition strategy by Microsoft

Back to The Future



Sorry for the absence. It's been a bit hectic while the Health Train travelled from Georgia to Southern California. (from green to brown)....from bugs to lizards and snakes.

I am on a sabbatical and expect to post much more from here.

I now have an internet connection and am able to catch up on some of my favorite bloggers,  KevinMD, Dr Wes, Edwin Leap, Medinnovation, and more, most of whom are listed on sidebar, with their links.

I admit I have been blog and healthcare reform fasting. I am not totally in 'remission' yet. I am weighing whether to continue my avid interest and advocacy for continuing health reform. I feel I need to contribute to bettering our health system.

The next ten years will see radical changes in health care delivery.

Some of what was once thought of as 'unethical' by practitioners will become commonplace.

See full size image

The rise of retail medical clinics will continue unabated, and the scope of their practice will extend to management of hypertension, diabetes mellitus in addtion to other common maladies of body and spirit.

To survive, primary care practices will need to adopt electronic information systems, not just to increase efficiency, but to satisfy insurance and governmental requirements to obtain complete reimbursements, without penalties.

Retail medical clinics already employ these systems and are an integral part of their operations.

Physicians will either adapt or be swept aside. We must prepare the next generation for what they will deal with once they are finished with medical school.

Medical education itself is undergoing a transformation in funding.  The federal government has bypassed private banks for funding undergraduate medical education.  This will allow the federal government to specify who will get financial assistance,as well as  possible later waivers on loan repayment.  Medical students may be required to sign a contract agreeing to serve in underserved communities or less desirable practice locations. Perhaps it may be year for year.  These students will become civil servants.  They will be required to develop multi-cultural skills, and to demonstrate their literacy and verbal skills in Spanish.

The lack of enrolling minority groups, African American and/or Latino will encourage the federal government to aid schools by forcing them to accept lesser qualified candidates for acceptance to medical schools.  This does not appear to be a problem for Asian students who mostly excel in secondary and undergraduate colleges.

The "cell" generation will generate a strong market pressure to allow developers to build EMRs that will run on smartphone, such as the iPod.  These systems will integrate almost seamlessly with the office EMR  and/ PM systems.

Patients will no longer use a yellow page listing to find providers, they will utilize the internet, and at times find poor providers. Ths will drive state and federal officials to require documentation to be listed on internet search engines.  Commercial web sites such as healthgrades will not be a credible source for paid listings.

Despite the evolution EMR and Health IT, it will be found to not  save money or enable providers.  In fact it will reduce provider efficiency unless they are radically designed to be user friendly as a priority over meaningful use.  The term meaningful use will have been discarded, to be replaced with "Specialty specific Design. Meaningful use with be specific for each specialty.

Remote telemedicine and monitoring will become commonplace. The Federal and State governments will adapt their reimbursement method to pay for most of these costs when an analysis reveals that remote monitoring reduces inpatient admissions drastically,  and reduces the number of outpatient visits. 

All  of the home devices will be wireless and connect automatically to the home network and the specified instrument monitoring service. For those without broadband, dial up will be an alternative.  Just as providers now are required to have a national provider identification number, patients will also be assigned one at birth or on the occassion of their next birthday. The number will be unique to the medical system for a number of important security issues, and prevention of fraud.

Written signatures for consents, hospital admission and discharge and medical office registraton will be supplanted by biometric identification, either infrared fingerprint recognition or iris recognition.  It will no longer be necessary to provide an insurance identification card to a provider or hospital. 

Freedom of choice will be reduced for most patients.


Thursday, April 15, 2010

Health Insurers Investment in Fast Food

Food for Thought??  from The WSJ Health Blog

Should life and health insurers be investing in the stocks of fast-food companies?

Researchers at the Cambridge Health Alliance, which is associated with Harvard Medical School, say no, citing the downside of fast food — associations with obesity and other health problems, heavy marketing to kids and the the chains’ environmental impact. Insurers, however, do have a responsibility to share- or policyholders to maximize returns, and that may include investments in companies that don’t share their health-promoting mission, they say.

Sensing that potential disconnect, the Cambridge researchers set out to find out the value of major insurers’ investments in the five leading fast-food companies:


Jack in the Box, McDonald’s, Burger King, Yum Brands and Wendy’s/Arby’s. Based on shareholder data from the Icarus database, they calculated the insurers’ combined fast-food holdings totaled $1.88 billion as of last June. Their findings, including a breakdown by company, are published today in the American Journal of Public Health.

See full size image

However, as with a similar analysis last year of tobacco stock holdings by insurers, companies disputed the numbers. MassMutual spokesman Mark Cybulski says the study’s calculations of $366.5 million were “absolutely incorrect.” In an email, he didn’t give an alternative number for June, but said that as of Dec. 31, the insurer’s fast-food related holdings were $1.4 million in a portfolio totaling $86.6 billion in cash and invested assets.

Northwestern Mutual held $422.2 million in fast-food stocks, according to the study; spokeswoman Jean Towell says that number is in error. At the time the data was collected the company had less than $257 million in holdings, about 0.19% of its general portfolio, and now that’s down to about $248 million, or 0.17%, she says.

Prudential Financial spokesman Bob DeFillippo said he couldn’t verify if the study’s $355.5 million calculation was accurate, and added that Prudential never talks about individual holdings, anyway. And, he says, many of the stocks are likely held in index funds for clients, meaning the insurer didn’t select the stocks but held them usually only because the stocks were index components.

Study author J. Wesley Boyd, an attending psychiatrist at CHA and assistant professor at Harvard, defends the numbers, saying according to the database they were correct. He says the U.S. companies studied were primarily life insurers and don’t sell health insurance per se, but that some of the Canadian and U.K. companies covered in the study do sell health insurance.

Why should we care whether a life or health insurer invests its money? “They’re profiting directly off the people who eat fast food, and if that leads to obesity or cardiovascular disease, they’ll charge you more for premiums if you have some of those conditions,” says Boyd. “They’re making money in either case.” The researchers say another option besides divestment is becoming activist investors in fast-food companies to push for changes such as lower-calorie menu options or different marketing policies.

Thursday, April 1, 2010

Choosing a career

I remember chosing medicine as a career because I wanted to use whatever talent I had to help patients with their health and lives. At that time I was studying engineering. I was one of those people that could not make up their mind what I would do with the rest of my life. I would pick a topic, master it, and then move on to the next interest. Even after I earned my medical degree it took some time for me to pick a specialty. I stopped for a bit of time to direct an emergency medical group and practiced general medicine for several years. It was very interesting and stimulating. Perhaps I learned as much in those four years as I did in medical school and internship. I had no problems in finding specialists to manage problems that went beyond my relative inexperience to help my patients where I left off.


I left emergency medicine because at that time it was not a recognized medical specialty, and only after I left was the specialty formalized with board certification. I was one of the founders of the American College of Emergency Physicians. However I did not see a 'future' for me in ER medicine. There was little if any long term patient involvement.

I rarely had any follow after the patient was discharged from the ER, unless they were admitted. I also found out quickly that ER physicians do not have hospital privileges. (perhaps this has changed). Surgeons, orthopedists, internal medicine doctors openly looked down on ER doctors as those who did not or could not finish specialty training. Becoming an ER doctor had a negative implication on your intelligence and capability..

In those days it was a challenge to have a specialist come in to see an ER patient. Many were uninsured, and less than socially desirable patients. (things have not changed very much), although more patients, and even those with insurance resort to the ER when their physicians are not available. It has always functioned as a pressure relief valve or safety net for those otherwise unable to see a primary care doctor.

There are many reason why medical students chose not to enter general medicine..


The status of nurse practitioners and physician assistants has been elevated to the point where they can diagnose and/or treat 90% of common problems, and they do not have to have hospital staff privileges. Throughout medical school, unless one is fortunate enough to have a family medicine or clinic rotation the general consensus is that the best and brightest do not enter primary care medicine. Those who chose this field are looked askance at and trivialized as not requiring advanced clinical skills. The training programs are top loaded for gaining skills not at medical school, but later in postgraduate training, beyond the internship.


The reimbursement equation has not favored primary care, pediatrics, or internal medicine. The American system is based on procedural coding, not cognitive time or processing. Even the codes presently in existence for evaluation and management are inadequate, especially for time intensive issues. There are no codes for administrative time, medical record keeping, telephone consultations, telemedicine, or patient education time, hence it is either left to medical assistants or worse, ignored entirely.


Health reform will not alter the science of medicine. It will obstruct the smooth flow of our activities, and create time wasting administration which physicians will pay for as an operating expense, whether in private practice, group or government medicine. Administrators have and will control executive functions and physicians


Physicians will continue to care for patients, do research, do surgery, have good and bad outcomes regardless of fines, audits, quality assurance, pay for performance, EMR, incentives, penalties or other nameless ideas.