Health Information Exchanges and Electronic Medical Records Part II

 

Part I in my previous blog   ………………

 

I describe HITECH and APPA and the negative reward system to create incentives for physicians and hospitals to acquire and use electronic medical records.

 

Today I am going to describe several critical and key issues which will greatly impact on providers in their daily work.

Here is the scenario.

Dr Gofaster is an internal medicine physician who attends patients at two different hospitals, BeHospitalized Medical Center and Don’tbeAdmiited Center for Cardiac Arrest.  He is on call for both E.Ds

His iPhone do it all sounds an alarm and he receives an SMS from BHMC E.D. Dr Gofaster sees the patient and records his EMR for patient  I.Dont Wantadiehere.  Following admission the next day he sees his patient but is unable to see the ED notes because the outpatient system is entirely different and not connected to the inpatient EMR. (my experience in the federal US Army AHLTA system.)  He experiences some difficulty using the two differing systems in one hospital.

 

Dr Gofaster’s iPhone do it all goes off again summoning him to the ED at DBAMC.  He arrives in five minutes, sees the patient and has a problem using the entirely different EMR in the second ED.  After admission he goes to the floor and sees another inpatient. He is again stymied using the inpatient EMR since it is different from BHMC.  He either forgot his password or left it in his wallet in the car.

Summary,  two different hospitals,  Four different EMRs

Four different passwords that require changes every 90 days.

Dr Nowslowingdownmore attempts to enter his password incorrectly three times in a row…the system now tells him he is locked out and he must answer 4 challenge questions, which  he cannot remember nor answer.

  His alternate choice is to dial 1-800-IDONT-SEE-PATIENTS, he is placed on hold after answering four voice mail prompts,  #,@,!,&,&  unless it is on the weekend when he must enter at least 1 number,  one  upper case letter, one lower case letter, and be no less than ten digits long.

Upon contacting a support specialist (who is in Singapore) he is asked what version is his hospital software.

Thirty minutes later he is  ready to record his EMR.  As he logs in the log in page announces that the system is down for the next 4 hours for maintenance, with the message. “We are sorry to inconvenience you, doctor.

Dr Nowslowingdownmore heads to his office and starts his workday in the office.  He enters the first patient room. Patient

I.Wantagohome is pacing because he needs to leave (he is an attorney)  Dr N. Slowingdownmore attempts to log in his office system, but receives a message

he must change his password and he cannot use any of his old passwords.  He is locked out while attempting to answer two of his six alternate secret questions and answers.

 

Dr N.Slowingdownmore gives it up and pulls out his trusty No.2 yellow pencil and waits ten minutes while Betsy tries to find a progress notes sheet (they are buried under some old floor mops in the storage room).  Dr. Slowingdownmore notes that his pencil has never been sharpened and their are no pencil sharpeners, so he pulls out a scalpel  blade to sharpen it.  In the process he slices the tip of his index finger on his writing hand off.

Dr. S swears loudly, throws his iPhone against the wall, shattering it as it falls to the floor. 

His medical assistant  Suzie Icantakeitanymore brings in a certified letter from the medical staff office placing him on probation due to his incomplete hospital  charts.

Get the picture, all you do-goody HIT folks and Politicos???

Names have been changed to protect the guilty.

Health Information Exchanges and Electronic Medical Record Negative Reward Incentives

 

 

Health Information Exchanges and Electronic Medical Record Negative Reward Incentives are still controversial. The American Recovery and Reinvestment Act includes a wide variety of mandates, including HITECH to stimulate acquisition of EMR and building a national health information exchange network.

As a student and consultant of health information exchange development and the federal and state government incentives for ‘rapid’ development’ of medical digital records, I am struck at the lack of organized medicine’s and individual practitioners opinions regarding EMRs.

Congress has been sold a ‘bill of goods’ much like buying the Brooklyn Bridge for $1.00. (And the price will go up next year if you don’t buy it now). This is very much snake oil medicine, at its worst.

Let me be clear about one thing.  I am not anti-EMR or anti-HIE development.  The present developmental plans benefits mostly health information technology vendors

I am not a Luddite, by any means, however from all the information I have been able to gather, there are few if any  studies that document meaningful return on investment.

This “catalytic innovation”, a term which I coined five years, ago is a disruptive technology.

Physicians and patients should contact our senators and representatives in Congress and at the state level to change the formula for incentives. The EMR products offered to physician practices and consumer electronic health records,  are not mature enough to invest billions of dollars at the taxpayer’s expense. The timeline is defective in several ways.

1. Evaluation, study and implementation also require training time.

2. The HIT industry does not have the manpower and/or resources to accomplish this within the specified time period.

3. There has been very limited success for practitioners and hospitals to adopt EMR.

4. The impact of the health reform legislation has yet to be determined on the overall cost of health care. Numerous early studies indicate the cost to the consumer will rise substantially with health reform. Certainly the stated goals are admirable for our society. Early indicators are that the insurance industry will do it’s best to maximize profit during the early years of health reform as a hedge against future legislation requiring expanded coverage of benefits and the mandates from the states to eliminate the ‘uninsured’. States are not in the health care business and previous experience with major risk policies reveals that States depend upon private insurers to manage and indemnify the policies and operate Medicaid and Medicaid HMOs. The same market forces will continue to impact the model and many insurers will refuse to offer these policies or drop contracts with the state.

5. It will require several more years prior to penalizing those who do not adopt EMR, when the current  products of choice are inadequate, and based upon old models of billing and collections.

6. Certainly if the stated goal of medical homes as well as non-procedural reimbursement methodology the present plan is not in line with the goals of increasing efficiency, nor collecting meaningful information. Our currently available EMR  systems address neither the purported goal of meaningful data for individual practices, nor promoting best outcomes. The current Gantt chart time line will  stimulate the acquisition of poorly designed clinical information systems.

7. The term meaningful use (for whom?) is inadequate and is not defined in terms of the differing type of practices, or hospitals.

more……in my next blog post.

 

LiveJournal Tags: emr,meaningful use,health information exchange,health reform,emr incentive,health train express

Rising Stars in Health Reform

Sermo has arisen in the past three years as a powerful media voice for the grass roots of physicians.

FOR IMMEDIATE RELEASE

Sermo Named to Fast Company Magazine’s List of World’s Most Innovative Companies

Largest Physician Community Recognized as ‘Political Force’ Behind Healthcare Reform Efforts

Cambridge, MA, February 24, 2010 — Sermo (http://www.sermo.com), the world’s largest online community for physicians, today announced it has been named to Fast Company Magazine’s list of the world's most innovative companies. Sermo earned its ranking for providing a free web service – referenced by Fast Company as a ‘facebook for doctors’ - where physicians can collaborate and improve patient care. The company was also cited as a ‘political force’ after 11,500 physician members composed, signed and delivered a petition opposing the American Medical Association's acceptance of the House healthcare reform bill in the summer of 2009.

To create this year’s list, Fast Company’s editorial team analyzed information on thousands of businesses across the globe to identify creative models and progressive cultures. Sermo was recognized alongside the most respected healthcare innovators in the world, including athenahealth, GE, Cisco, Patientslikeme, and Kaiser Permanente.

“Since launching in 2006, more than 20% of all US physicians have joined the Sermo community,” said Dr. Daniel Palestrant, CEO & Founder of Sermo. “As the physician community has grown, so too has our client list, which now includes 10 of the top 12 pharmaceutical companies. These companies are engaging physicians through our social media offerings built specifically to increase brand awareness and provide valuable market intelligence not possible through other channels.”

Unlike other models, Sermo is free of advertising and free to physicians. Revenue is generated as clients purchase products to interact with specialists. To learn more about Sermo’s social media offerings, visit www.sermo.com/clients.

The complete Fast Company Most Innovative Companies list and related stories appear in the March 2010 issue of Fast Company magazine, on newsstands currently and online at www.fastcompany.com/MIC.

About Sermo
Sermo is the largest online physician community, where over 112,000 physicians collaborate to improve patient care. Sermo provides access to its community for clients that need fast, actionable insights into treatments, drugs and devices. Learn more at www.sermo.com.

Of some interest is the fact that Sermo and the AMA originally were in a partnership which dissolved within the first  year of their agreement.  Sermo’s contention is that the AMA does not truly represent any majority of American Physicians and  has a conflict of interest in holding the copyright for the CPT codes.

 

Another embryonic politically active forum is Docs4Patientcare.org   This organization abruptly sprouted last year during the health reform debates. For more information go to their website. 

Health 2.0 International

Please click to expand to fill screen

 

 

Medical Social Networking has gone global, from the U.S. to the U.K. and beyond into specialty societies.

A quick google search will bring up many social networking sites, some with authentication required, membership requirements,and also open networks.

The Elephant in the Boa Constrictor

Richard Reece M.D. who writes Medinnovation Blog aptly analogized HIT  and the Government. 

The Elephant in the Room

Before resigning in frustration as the first “HIT Czar,” David Brailer observed in a 2005 in a New Times Times interview , “The elephant in the living room is what we’re trying to do is the small physician practice. That’s the hardest part, and it will bring this effort to its knees if we fail.”

The Blind Men and The Elephant

The second metaphor is the Blind Men and the Elephant. Our health care system is an elephant. Everyone feels the elephant’s parts differently. Doctors hanging on to the tail feel the system is an encircling rope, purchasers touching the leg feel it is an immovable tree, plans holding the trunk feel it is a squirming snake, and government officials riding on the head feel it as a global positioning satellite devices, capable of controlling the direction of the elephant.

 

As Dr Reece so eloquently espouses:

“What concerns me is what will come out the distal end of the boa constrictor once the digestive process ends.”

Certification Central

The ONC has announced the approval of both CCHIT and the Drummond Group as agents for certifying interoperability and other standards for EMR.  Both groups fulfilled the requirement of the ONC and the NIST.

 

This ruling should bring much relief to CCHIT and those vendors who have participated willingly and volunteered to develop and test the standards. CCHIT has been in operation since 2006.

 

Some were critical and concerned that CCHIT represented mainly vendors, while the Drummond Group would be more unbiased. Competition is always a good thing, and should enhance affordability for those vendors seeking certification for EMRs.

This is another ‘elephant for the boa constrictor to swallow.

 

Extra Extra Read All About It

Today’s online edition of the New England Journal of Medicine has two articles, one by Katherine Sebelius regarding the recent health reform legislation in the United States, and another article  by Nick Black, M.D. on the United Kingdom’s proposed  changes to the NHS.

The appearance of these two articles with almost inexplicable timing  reveals how two different systems see themselves as failures and are seeking to correct it by going in opposite directions. 

It begs the question, “Who is ahead in creating a ‘more perfect world?”

So goes California…so goes the Nation

or why we need less government.

The remainder of this post has been removed at the request of the copyright holder. Modern Medicine holds the rights to the content, and we are negotiating with them to license some portions of their material for this blog. Sorry.

Power to the People !!???

What people you may ask?  Ask and ye shall be told !!

Modern Medicine announced today the 100 MOST POWERFUL PEOPLE IN MEDICINE.

So, who makes  this momentous decision?? Is it more important than the ‘Golden Llama Award’?? (of which I unashamedly boast that I earned some time ago)

A little bit of research reveals that these mighty Centurions are chosen in this manner. 

Is it any wonder why most physicians are enraged and stand gawking with disbelief?

Dr Wes, in his blog today points out how the rules don’t count for those who make the rules

Should Dr. Emanuel not have noted his relationship as White House advisor for health care policy and his relationship with his brother, White House Chief of Staff Rahm Emanuel? And should Ms. DeParle's disclosed her role as President Obama's so-called health czar with significant ties to private equity firms?

Conflict of interest exists when an author, editor, or peer reviewer has a competing interest that could unduly influence (or be perceived to do so) his or her responsibilities in the publication process. The potential for an author’s conflict of interest exists when he or she (or the author’s institution or employer) has personal or financial relationships that could influence (bias) his or her actions. These relationships vary from those with negligible potential to influence judgment to those with great potential to influence judgment. Not all relationships represent true conflict of interest. Conflict of interest can exist whether or not an individual believes that the relationship affects his or her scientific judgment.
Authors, editors, and peer reviewers must state explicitly whether potential conflicts do or do not exist. Academic, financial, institutional, and personal relationships (such as employment, consultancies, close colleague or family ties, honoraria for advice or public speaking, service on advisory boards or medical education companies, stock ownership or options, paid expert testimony, grants or patents received or pending, and royalties) are potential conflicts of interest that could undermine the credibility of the journal, the authors, and science itself.

Perhaps such disclosures only for the little people in health care who try to publish their work.

 

And finally  Dr Wes offers this list as the 10 most important (and powerful ) people in Medicine:

So who are the most powerful people in health care?
Well, I'd like to propose my list - maybe not of a 100 people (frankly, nothing gets done if you have a committee of 100 people anyway) - but rather my own list of the Top 10 Most Powerful People in Your Health Care today:

10. The Doctor - They consider the differential, write the orders, follow-up on tests, and move the health care ball forward throughout your hospitalization or stay with a rehab facility. As such, they should be given their power due, even if many other members of the health care team are actually are the ones that make sure the care happens. Still, because the doctor gets most of the liability risk if things don't happen or happen incorrectly, they just make my power list.
9. The Food Service Personnel - These folks are powerful. They have the ability to make even a clear liquid diet look like real food - especially when they mix the colors and flavors of jello. Further, proper parenteral nutrition for an ICD patient greatly shortens the sickest patient's hospitalization. Get it right and everyone benefits. Power personified.
8. The Physical Therapist - If you can't eat your food, sit up, keep your muscles toned, maintain the range of motion of your limbs when sick, the chances of returning to independent living are limited. Physical therapist have come of the most helpful techniques to get going - both physically and mentally - like turkey bowling. Their power over our patients should definitely be appreciated more.
7. The Social Worker - Want to negotiate the complex Medicare and Medicaid rules for placement in an assisted living facility? Need to get a patient to rehab? Want to arrange transportation for a patient that doesn't have a penny to their name? Make something from absolutely nothing? Call the Social Worker - but call them early in the hospital stay. (They're never at their best with last-minute consults.)
6. The Nursing Supervisor - Trust me on this. No one has more power to assure adequate staffing on each patient care ward each day than the Nursing Supervisor. Medical students and residents that cross the directives issued by this individual do so at their own peril.
5. The Bed Coordinator - If you need to admit a patient to a hospital, they must first get a bed. With many hospitals working at or near capacity, no single person has more influence over the patients admitted to a hospital facility. They find beds when no one else can. After all, it's their job.
4. The Hospital Operator - Name one person who can activate a Code Blue (cardiac arrest), find the obscure specialist in the middle of the night when they're most needed, or mobilize a trauma team faster. Can't do it? That, my friends, is power.
3. The Night Shift Nurse - At three in the morning when you're lying there in the hospital bed and need something - anything - who's the most important person in the hospital who will assure you're needs are tended to? Need I say more? If the night shift nurse is inattentive, unresponsive, irresponsible for that 8-hour shift - you're screwed. On the other hand, if she's attentive, knows when to call for help, or provides pain relief when you need it most after surgery, or - most important - gives you that laxative at 3AM - his or her power in medicine pales in comparison to any bureaucrat, politician, or hospital system CEO.
2. The Patient's Family - Often forgotten, family members have huge influence over the care provided to their loved one - especially at times where their loved one might not be able to communicate. This power should not be ignored, but it cuts both ways, too. While family members can facilitate the treatment and rehabilitation of their loved one because they know them better than anyone else, they can also prolong undue suffering if they do not comprehend the limits of care that their loved one desires in the end-of-life setting. Families that communicate their needs and wishes before anyone gets sick avoid much of the confusion during this difficult time and serve as powerful allies to the health care team.
1. You, The Patient - No one has more influence and power over their care than you. Don't want care? Leave. No one can stop you. Want care and don't have a penny? Come to the Emergency Room. You won't be turned away. Wonder what all the big buildings, waterfalls, and fancy technology were built and bought for? You. Every single person involved in health care is there because of you. So make the most of it. Come prepared. Know your medical history, medicines and allergies. If you can't remember, keep a list with you. Ask questions. Insist on clear answers. Work with your care givers, don't fight them. If you're not sure, get a second opinion. Write a letter acknowledging those that made the extra effort and scolding those that didn't. Your constructive criticism makes the system better. And know that hospitals understand the importance of your word-of-mouth referral - it's the most powerful marketing strategy a health care system can generate. Finally, remember that you can vote for politicians that don't forget who's in charge. You are the ultimate power broker in health care. Don't forget it.

-Wes

Musings of a cardiologist and cardiac electro physiologist.

And Thank you to the most powerful electophysiologist in the blog world….make my milliamps…Dr Wes

LiveJournal Tags: modern healthcare,Dr Wes,conflicts,healthtrain express

Health Reform in the NHS vs.. The U.S.

 

        

 

Surprise!! The U.K.s NHS system is running away from itself as fast as Obama and Berwick are running toward an obsolete model.

From the  BBC News Online  today,

Hospitals are to be set free from central control

 

“Unison has launched legal action against the government's plans for a major shake-up of the NHS system in England.

The UK's largest public service union claims ministers failed to ask the public if it wanted such fundamental changes in the first place.

The proposals in the health White Paper would hand the responsibility for most health services to GPs.

A consultation on how the changes would be implemented ends on 5 October 2010.

A Department of Health spokeswoman said the government was engaging fully with the public, healthcare professionals, local authorities and unions on how its proposals will be implemented.

Continue reading the main story

“Start Quote

Far from liberating the NHS, these proposals will tie it up in knots for years to come - they are a recipe for more privatization and less stability”

End Quote Karen Jennings Unison

But Unison argues the public's view on the White Paper proposals has not being requested and will not be considered.

Karen Jennings, Unison head of health, said: "The White Paper contains sweeping changes to the NHS and how it should be run.

Continue reading the main story

Related stories

• NHS 'to undergo radical overhaul'

"The NHS Constitution enshrines the principle that the public, staff and unions have an absolute right to be consulted. And that means not only on how the proposals are to be implemented, but also whether they should go ahead in the first place.

"The Department of Health's refusal to recognize this clear and important legal duty leaves us no option but to issue legal proceedings as a matter of urgency."

Unison said that the day after the White Paper was published, NHS chief executive Sir David Nicholson wrote to all NHS chief executives instructing them to start implementing the proposals "immediately".

The union maintains this was unlawful, but the Department of Health disagrees.

A spokeswoman said Sir David Nicholson's letter encouraged the NHS to begin locally led consultations and take first steps on the implementation of the White Paper, without pre-empting the wider consultation.

"Many reforms are also subject to Parliamentary approval as part of the Health Bill.

"Through the proposed changes, healthcare professionals and patients will have more power to shape, lead and deliver local healthcare services, away from the control of central Government," she said. (emphasis mine)

Unison believes the White Paper opens the door to privatization of the health service, and warns it would plunge the NHS into "chaos".

Ms Jennings said: "Far from liberating the NHS, these proposals will tie it up in knots for years to come - they are a recipe for more privatization and less stability."

 

It seems the U.K. NHS has it’s own problems with transparency and changes. 

LiveJournal Tags: NHS,CMS,UNIONS,UNISON

Innovation

It goes something like this:

Bill Gates:

 

So, the underlying question is what will Obamacare do for innovation in health care.

 

Perhaps it will drive further innovation to radically change our paradigm for delivering healthcare and improving wellness.

Did congress set off the spark for innovation?

Will innovators enter medical practice?

Diabetes and it’s Complications

Normally I post articles on health reform, and information technology.

However today I was in the process of preparing examination questions for board preparation for the American Board of Ophthalmoloogy, and came upon this poignant observation by a medical resident.

It also points out the importance of tight glycemic control for diabetic patients.

Insight

Elizabeth B. Gay, MD
Charlottesville, Virginia
eg3d@hscmail.mcc.virginia.edu

JAMA. 2010;303(3):205.

The right eye bleeds on a Wednesday morning. I am walking to clinic, heading up the hill on 97th Street. For a moment, I imagine the dark spot is some trick of light and shadow. But it grows before me, spreading outward from its center, forming a web across my vision.

I know the correct medical language—vitreal hemorrhage—

but can only think: My eye is bleeding. The growing web floats across the world, almost beautiful if I weren't so afraid. I had a laser treatment on this eye two days ago, to prevent fragile new vessels from bleeding.

The right eye has always been the good eye; the left has been bleeding for a year, despite more laser sessions than I can count. I know I will need a vitrectomy

 

on the left eye, but I was counting on the right. This bleeding is the result of diabetic retinopathy and so particularly painful because it is in part my fault. Previously obsessive about my blood glucose, during my intern year of medicine residency, exhilarated and exhausted by the rigors of training, I struggled for reasonable control. And I let myself be 180 rather than 80, given the inconvenience of being low. My blurry vision feels like punishment, and usually I believe it's deserved.

I keep walking to clinic because there's nothing to be done right away—I can't have more laser after only two days. It is a perfect fall day, clear and sunny, but it is disappearing under a growing darkness. I am afraid that I will never again experience this sharp morning light, that I will always remember this morning as a moment of loss. Practical concerns add to my sense of despair: I’m on call for the ICU in two days, and the vision in my left eye is already blurry. I need the right eye to function. Of course this need doesn't matter, the body impervious to my panicked mind.

Clinic is chaotic as usual, and I abandon any attempt to read scribbled chart notes. On the computer I enlarge the font, grateful for modern technology. And most of what I need to know, patients tell me. Somehow the day goes on. This is how it's done, this is how people cope with illness. You go on because there is no choice. You go to work and do the best you can. Medicine is a good job because it's easy to forget yourself. Working in the ICU on Thanksgiving Day, I tell myself that the threat of blindness is less than what my patients face. I hold in my mind images of bravery offered to me every day, families who pull together to make unbearable decisions about the end of life, patients who somehow find pleasure in being an "interesting patient." But I can't quite convince myself. I would prefer the threat of death to that of blindness. Reading for me seems as essential as breathing, as impossible to live without. And then there is this: What if I can't do the job I’ve been working toward for eight years? But it is more than that because it's somehow become more than a job: it's become who I am. I am afraid that if I can't be a physician, I will lose my self.

I am saved by medicine after all, by a superb ophthalmologist and his colleague who skillfully remove the vitreous of my left, then my right eye. After each operation I must keep my head parallel to the floor for three days. This is the posture of defeat, the posture of despair, and it is hard not to feel it. The metaphor of the darkest hour becomes real for me in those first days after the second operation, both eyes recovering, a time when faces are blurry and indistinct. I am acutely aware of time as a palpable dimension, made to pass by music and books on tape. My vision slowly improves, leaving me able to do my job, and determined never to complain about having to do it, never to whine about returning in the middle of the night to the ICU, never to complain about a presentation or journal club. And every morning I am both grateful to be able to see and afraid it might not last. I am like my patients, like all survivors of illness, left with gratitude and uncertainty, wonder and fear.

A Piece of My Mind Section Editor: Roxanne K. Young, Associate Senior Editor.

LiveJournal Tags: health train,diabetic retinopathy,laser,anti-vegf

Some Inspirational Art

I was about to fold my tent this evening after a long day of writing, however as I was finishing my evening rounds on blog lines, my favorite RSS aggregator, I came upon this….

I need to share what I consider an outstanding post by Regina Holliday and here almost biblical art work that reminds me of the last supper, Moses receiving the ten commandments. the parting of the red sea, and the last supper.

 

SHARE THIS WITH ME,  and thank you Regina….what a wonderful way to turn off the day.

GML