Wisdom on the Health Train Express

from 'GOOZNEWS'

Technology isn’t a quick fix. Just ask General Motors. In the 1980s, the auto giant spent $50 billion to automate and computerize its plants in an effort to compete with Toyota. Today, GM is emerging from bankruptcy while Toyota still leads in producing high quality, fuel-efficient vehicles.

What happened? “The Japanese have a great way of describing the error that General Motors made,” said Thomas Kochan, co-director of the Institute for Work and Employment Research at the Massachusetts Institute of Technology Sloan School of Management. “It’s workers who give wisdom to these machines.”

(underlining, mine)

The analogy between the auto industry and health IT is obvious.

Will the Obama administration’s $20 billion push to flood the nation’s physician offices and hospitals with electronic medical records (EMRs) suffer a similar fate?

“Technology doesn’t change lives,” Riley said. “It’s the process around the technology that brings results.”

I think this is what doctors are talking about in their reticence to accept EMRs into their practices. What is good for the goose, is not necessarily good for the gander.  Small practices (group, or otherwise) are different administrative animals than large and even huge integrated health care systems.

An easily observed manifestation of this is what I call the 'walkaround"   Walk around a typical small group or solo practice and compare the square footage in a smaller practice  dedicated to clinical care space, and administrative space.  Where is the administrative space? In these large entities, those with the nicest offices with a 'view' are the nurse case managers, heads of departments, and executive administrators.  This is obvious when one tours a VA hospital, Army, Navy hospital and Kaiser Permanente. 

Are these administrators 'evil people"?  No, however the pecking order and corporate culture encourage this development of space allocation, especially since administrators control the purse strings.  I have even heard practice managers discourage allotting a comfortable 'thought room" because doctors don't see patients in their "personal office space".

More on this in my next post. I have a patient waiting and have to leave my 'personal space' (100 square feet).

The Art part of Health Care Reform?

M.D.: Where Is the Art of Medicine in Health-Care Debate?

Abraham Verghese MD discusses the objective of tying reimbursement to the time involved with seeing a patient. Attempts at this were made with the development of Evaluation and Management coding. (E/M coding). Unfortunately the criteria for these codes do not include many factors in patient management that have no relevant coding measures. E/M coding is strictly limited by body system evaluations, and depending upon the clinical focus are inappropriate. The coding measures have always been insufficient. There are no codes that reimburse for coordinating patient care with other providers, nor for administrative time involved in justifying payments to payers, including medicare.

Everybody’s got something to say about health reform, but nobody’s speaking up for the art of medicine, Abraham Verghese argues today in a Wsj.com column.

Many doctors’ groups and academic medical centers are too deeply entrenched in the business of medicine to speak up for the field’s noblest intentions, writes Verghese, a novelist, Stanford prof and practicing physician.

And he makes a case that a payment system that encourages doctors to practice the kind of medicine that leads to real relationships with patients could be more efficient in the long run: “Our esteemed medical societies and academies aren't speaking for medicine; they are lobbyists, defending their financial self-interests, lining up for or against the latest bill being proposed. Our great academic institutions and our esteemed medical schools have historically spoken for the cause of medicine, but these days many medical schools are more like big companies with complex financial interests in large hospitals and clinical practices. What about the large foundations dedicated to health care, such as the Robert Wood Johnson Foundation or the Kaiser Family Foundation? I think their voices have become more potent as they seem largely free of the kinds of conflicts of interest that bind many of us, but they are not quite the voice of medicine.”

Howard Dean meets SERMO

The power of the internet has become apparent in national and local political decision making. Politicians use the internet and watch bloggers and social networking sites to measure carefully their decisions. No longer do groups have to use expensive s elf serving lobbyists to get their point across.

Yesterday SERMO participated in a nationwide forum (debate) with Howard Dean on CNBC. Sermo put forth the concept that the AMA does not represent either the majority of physicians, nor their opinions.

Howard Dean himself indicated that he does not belong to the AMA. It was  a very contentious meeting. Dan Palestrant who spoke for SERMO and it’s 110,000 members focused on the need for tort reform and reimbursement reform. Howard Dean expressed his belief that doctors on salary would do away with the demons of our present system. Palestrant focused upon level of reimbursement being adjusted for level of training. Dr. Palestrant indicated the AMA has a self serving interest in reimbursement since it holds important copyrights to the CPT (current procedural terminology), which all insurance companies and Medicare, as well as DOD, and VA system use on a daily basis. (ie,insurance companies pay the AMA for their right to use CPT codes.) The AMA garners a great deal of income from that source. The interview was too short, abbreviated, and neither participants had sufficient time to give a coherent presentation to lay audiences.

I think the most important take away was that a large group of physicians had a national platform other than the AMA. Hopefully Congress has paid attention.

SERMO and the AMA

Daniel Palestrant MD of Sermo discusses health reform issues with Howard Dean, former Governor of Vermont

Health Reform....is Health IT mandatory?

One of the greatest discoveries a man makes, one of his great surprises, is to find he can do what he was afraid he couldn't do. Henry Ford

 

[Shades of the Past!

 

Jeff Marion of  EHR watch .com shares this commentary from Shahid Shah.

Guest Article: Why do Doctors Hate EMRs???

There is also an audio cast on the web site, for those who like to multi-task, listening and /or reading content.

Some interesting quotes regarding the appraisal of typical EMR software.

How do we know doctors hate EMRs? Look at anemic adoption rates.

When such features as e-prescribing, e-visit, and PHR integration are considered, it is likely than less than half of physicians use their EMR for little more than their own templates and a few favorite features. The majority of physicians have voted with their feet.

In the business community it is common to hear doctors referred to as computer-phobic and “in denial” about the benefits of computing. That is wonderfully ironic when heard alongside chronic complaints that doctors are overly eager to use expensive technology: lasers, cryro-probes, fiber optics, MRI and PET scanners, stents, and implants. The fact is that doctors love high-tech.

They have reason to hate EMRs but not computers and iPhones.

Most physicians receive their first scars at the hands of hospital software. The truly unlucky have experienced a software installation with conversion from paper to EHR.

Physicians know that better exists. They have experienced Google, Amazon and e-Bay. Game lovers know that Electronic Arts’ “Tiberium,” now 15 years old, exceeds the capabilities of their professional health care software. They know from Yahoo and MSN the value of configuring a home page suited to delivering niche-information of their own preference. They know from using Word and Word Perfect that they can create precision documents merely by tweaking a template. They know they can use voice commands to make a phone call on their Blackberry.

They know that they can find drug information more easily on Google than proprietary software. They suspect that if their EHRs and EMRs had physician-specific home page functionality, that they could drop and drag orders, answer FAQs, dictate letters, and save time with templates with many fewer clicks. Ordering medications should be as safe and uncomplicated as using E*Trade.

Today most EHRs and EMRs are invasive both to workflow and finances. While high cost is a significant barrier to physician adoption, workflow disruption remains the killer deterrent.

An example demo patient, a return visit for an office visit, was typical enough: an obese, diabetic female smoker with a pulmonary problem. Everything was point and click: select, enter, click, read, post—again and again, over and over. The visit timed out at 30 minutes (their calculation, not mine) not including the time spent by a nurse’s clicks and front-office clicks. Allowing for physicians’ differing styles and based on difficulty, I’d expect this visit to take half that time. The record created was excellent. In private practice, at two patients per hour, and at this level of complexity—say 12 to 14 patients per day—one should expect bankruptcy. One would make a better living running a Dairy Queen.

A sign at a dry-cleaner’s shop reads: Low Prices, High Quality, Fast Service: Pick One. The point of EMR design is not to “pick one.” And, I am not advocating modeling medical practice after that in a remote mission clinic where the only record is a toe-tag, although I should recognize that mission outcomes are remarkably good. In the real world you get what you measure. If the metric is the chart, and you are willing to sacrifice time, then have at it. Also, in the real world, physicians are not usually on salary with no increment of production payment. Physicians do not hate high-tech and they do not hate computers. They hate wasting time; they cannot afford it, and neither can our health care system.

A Voice in the Wilderness

How many times do you or other specialists watch the current issues affecting medical care, and go back to seeing patients, either because of lack of interest, or more likely time pressures and patient care overwhelm your ability to deliver quality care to patients?

Specialists rely upon their societies to get the  news to the AMA via their specialty representatives or through their local and county medical societies and again through their state medical societies.  Is this effective?

CNBC Debate To Feature Sermo Physicians

Live survey results on CNN

Recently SERMO conducted a survey regarding physician opinions of the AMA's effectivenss in representing physicians. Does their public image and lobbying truly reflect the grass roots views.  SERMO's survey, although small seems to represent a far different view.  95% of the survey respondents said NO.  While there are some that this is  not a valid or scientific study, it does reflect a troubling issue brewing amongst physicians.  The study is biased toward physicians using "NEW MEDIA" , social networking and the internet.  Yet this is an important new vehicle which is more democratic than our previous organizational democracy. It also represents the young movers and shakers who will assume and be affected by health reform proposals.

For those of you unfamiliar with SERMO, it is a web based site with specialty sections.  It began with mostly clinical discussions about cases, and therapeutic interventions.   It grew over the past two years to include  practice mangement, political issues, ethics, philosophy, and medical issues. It is also a direct line to pharmaceutical companies, and others who can tap into the statistics developed from  comments on SERMO.

Be INFORMED, and render your opinions. !!

The Nitty Gritty

The following is part of a series of original guest columns by the American Medical Association.

by J. James Rohack, M.D.

Physicians started this month with some good news from the White House. After intense AMA education and outreach, the administration announced that it would remove physician-administered drugs from the archaic formula used to determine Medicare physician payment rates.

This important development will significantly lower the costs of a permanent repeal of the current payment formula that projects yearly payment cuts to all physicians. This is key. There is no debate that the current formula is broken, but the cost of permanent reform has stood in the way of long-term action. Instead, Congress has stepped in at the eleventh hour for the last few years to stop yearly cuts to physician payments that would harm seniors’ access to care.

Over the years, spending on physician-administered drugs ballooned from $1.8 billion to $9.1 billion, growing three times faster than spending on actual physician services. When government number-crunchers add those figures into the physician payment formula, known as the Sustainable Growth Rate (SGR), overall physician volume appears to go up. The growth target in the formula is then reached sooner, sending payment rates down.

The irony is that physician-administered drugs should never have been part of the formula in the first place. Payment rates for drugs are not determined by the formula, and utilization is primarily driven by pharmaceutical advances and government policies. The AMA has long argued that it is not equitable or realistic to finance the cost of these life-saving drugs through cuts in physician payments.

Permanent Medicare physician payment reform must be part of comprehensive health reform this year. Medicare payments should cover the increasing cost of providing care so that seniors can be assured of continued access to physician care.

Members of Congress on both sides of the aisle have stated that the Medicare physician payment formula is broken and should be repealed. President Obama’s administration has helped clear the way to Congressional action by removing drugs from the formula.

J. James Rohack is President of the American Medical Association.

Related Posts:

• The long road to health reform
• Medicare reform
• An article found on the road
• Voters versus lobbyists
• It starts with physician payment reform

Posted at KevinMD.com. Stay updated and subscribe or follow me @KevinMD on Twitter.

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