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Electronic medical record systems (EMRs) have become a part of the work flow for more than half of all physicians in the U.S. and incentives are in place to bring that number up to 100% as soon as possible. Some hail this as a giant leap forward for healthcare, and in theory that is true. Unfortunately, EMRs have not yet achieved their potential in practice – as I have discussed in my recent blog posts about “how an EMR gave my patient syphillis,” in the provocative “EMRs are ground zero for the deterioration of patient care,” and in my explanation of how hospital pharmacists are often the last layer of protection against medical errors of EPIC proportions.
Considering that an EMR costs the average physician up to $70,000 to implement, and hospital systems in the hundreds of millions – it’s not surprising that the main “benefit” driving their adoption is improved coding and billing for reimbursement capture. The efficiencies associated with access to digital patient medical records for all Americans is tantalizing to government agencies and for-profit insurance companies managing the bill for most healthcare. But will this collective data improve patient care and save lives, or is it mostly a financial gambit for medical middle men? At this point, it seems to be the latter.
There are, however, some true benefits of EMRs that I have experienced – and to be fair, I wanted to provide a personal list of pros and cons for us to consider. Overall however, it seems to me that EMRs are contributing to a depersonalization of medicine – and I grieve for the lost hours genuine human interaction with my patients and peers. Though the costs of EMR implementation may be recouped with aggressive billing tactics, what we’re losing is harder to define. As the old saying goes, “What good is it for someone to gain the whole world, yet forfeit their soul?”
|Pros Of EMR
||Cons Of EMR
|Solves illegible handwriting issue
||Obscures key information with redundancy
|Speeds process of order entry and fulfillment
||Difficult to recall errors in time to stop/change
|May reduce redundant testing as old results available
||Facilitates excessive testing due to ease of order entry
|Allows cut and paste for rapid note writing
||Encourages plagiarism in lieu of critical thinking
|Improves ease of coding and billing to increase reimbursement
||Allows easy upcoding and overcharging
|Reminds physicians of evidence-based guidelines at point of care
||Takes focus from patient to computer
|Improves data mining capabilities for research and quality improvement
||Facilitates data breaches and health information hacking
|Has potential to improve information portability and inter-operability
||Has potential to leak personal healthcare information to employers and insurers
|May reduce errors associated with human element
||May increase carry forward errors and computer-generated mistakes
|Automated reminders keep documentation complete
||May increase “alert fatigue,” causing providers to ignore errors/drug interactions
|Can be accessed from home
||Steep learning curve for optimal use
|Can view radiologic studies and receive test results in one place
||Very expensive investment: staff training, tech support, ongoing software updates, etc.
|More tests available at the click of a button
||Encourages reliance on tests rather than physical exam/history
|Makes medicine data-centric
||Takes time away from face-to-face encounters
|Improved coordination of care
||Decrease in verbal hand-offs, causing key information to be lost
|Accessibility of health data to patients
||Potential for increased legal liability for physicians
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A physician friend of mine posted a copy of her Medicaid reimbursement on Facebook. Take a look at the charges compared to the actual reimbursement. She is paid between $6.82 and $17.54 for an hour of her time (i.e. on average, she makes less than minimum wage when treating a patient on Medicaid).
The enthusiasm about expanding Medicaid coverage to the previously uninsured seems misplaced. Improved “access” to the healthcare system via Medicaid programs surely cannot result in lasting coverage. In-network physicians will continue to dwindle as their office overhead exceeds meager reimbursement levels.
In reality, treating Medicaid patients is charity work. The fact that any physicians accept Medicaid is a testament to their generosity of spirit and missionary mindset. Expanding their pro bono workloads is nothing to cheer about. The Affordable Care Act’s “signature accomplishment” is tragically flawed – because offering health insurance to people that physicians cannot afford to accept is not better than being uninsured.
After all, improved access to nothing… offers nothing. Inviting physicians to work for less than minimum wage so that politicians can crow about millions of uninsured Americans now having access to healthcare, is ridiculous. Medicaid expansion is widening the gap between the haves and the have-nots. The saddest part is that the have-nots just don’t realize it yet.
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It’s no secret that medicine has become a highly specialized business. While generalists used to be in charge of most patient care 50 years ago, we have now splintered into extraordinarily granular specialties. Each organ system has its own specialty (e.g. gastroenterology, cardiology), and now parts of systems have their own experts (hepatologists, cardiac electrophysiologists) Even ophthalmologists have subspecialized into groups based on the part of the eye that they treat (retina specialists, neuro-ophthalmologists)!
This all comes as a response to the exponential increase in information and technology, making it impossible to truly master the diagnosis and treatment of all diseases and conditions. A narrowed scope allows for deeper expertise. But unfortunately, some of us forget to pull back from the minutiae to respect and appreciate what our peers are doing.
This became crystal clear to me when I read an interview with a cardiologist on the NPR blog. Dr. Eric Topol was making some enthusiastically sweeping statements about how technology would allow most medical care to take place in patient’s homes. He says,
“The hospital is an edifice we don’t need except for intensive care units and the operating room. [Everything else] can be done more safely, more conveniently, more economically in the patient’s bedroom.”
So with a casual wave of the hand, this physician thought leader has described a world without my specialty (Physical Medicine & Rehabilitation) – and all the good that we do to help patients who are devastated by sudden illness and trauma. I can’t imagine a patient with a high level spinal cord injury being sent from the ER to his bedroom to enjoy all the wonderful smartphone apps “…you can get for $35 now from China.” No, he needs ventilator care and weaning, careful monitoring for life-threatening autonomic dysreflexia, skin breakdown, bowel and bladder management, psychological treatment, and training in the use of all manner of assistive devices, including electronic wheelchairs adapted for movement with a sip and puff drive.
I’m sure that Dr. Topol would blush if he were questioned more closely about his statement regarding the lack of need for hospital-based care outside of the OR, ER and ICU. Surely he didn’t mean to say that inpatient rehab could be accomplished in a patient’s bedroom. That people could simply learn how to walk and talk again after a devastating stroke with the aid of a $35 smartphone?
But the problem is that policy wonks listen to statements like his and adopt the same attitude. It informs their approach to budget cuts and makes it ten times harder for rehab physicians to protect their facilities from financial ruin when the prevailing perception is that they’re a waste of resources because they’re not an ICU. Time and again research has shown that aggressive inpatient rehab programs can reduce hospital readmission rates, decrease the burden of care, improve functional independence and long term quality of life. But that evidence isn’t heeded because perception is nine tenths of reality, and CMS continues to add onerous admissions restrictions and layers of justification documentation for the purpose of decreasing its spend on inpatient rehab, regardless of patient benefit or long term cost savings.
Physician specialists operate in silos. Many are as far removed from the day-to-day work of their peers as are the policy wonks who decide the fate of specialty practices. Physicians who have an influential voice in healthcare must take that honor seriously, and stop causing friendly fire casualties. Because in this day and age of social media where hard news has given way to a cult of personality, an offhanded statement can color the opinion of those who hold the legislative pen. I certainly hope that cuts in hospital budgets will not land me in my bedroom one day, struggling to move and breathe without the hands-on care of hospitalists, nurses, therapists, and physiatrists – but with a very nice, insurance-provided Chinese smartphone.
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Physicians looking for part-time jobs to supplement their income may have run across advertisements for “lucrative” Medicare Advantage evaluation opportunities at CenseoHealth. Here’s a typical ad:
CenseoHealth is the leading Risk Adjustment provider for Medicare Advantage plans – with a network of more than 1,800 credentialed providers conducting over 20,000 member health evaluations a month. Due to our continued growth, we are currently looking to hire in-home physician evaluators to work in these states.
As a CenseoHealth physician, you will meet with Medicare Advantage members in their homes to conduct their annual medical history and physical evaluation.
Conduct evaluations when it’s convenient for you
Ongoing physicians can make $3,500 to $4,000 per week
Physicians who work 1-3 days per week can make $800 – $2,000
Travel and lodging expenses are covered, plus we provide a per diem reimbursement
Malpractice insurance is included
This position does not require you to prescribe medicine, order lab tests, do blood work, or alter the member’s current treatment regimen
Please contact us, for more information.
Director of Physician Recruiting
Sounds pretty good, right? Well here’s what they won’t tell you:
1. Low Hourly Pay. Compensation is $100 per completed evaluation – but you have to drive to each member’s house (sometimes an hour each way) to complete a 31 page history and physical exam. Members are often medically complex, cognitively impaired, and/or non-English speaking. In the end (after counting travel time, cancellations, scheduling snafus, and long hours completing paperwork and FedEx shipping) the hourly wage works out to be about $30.
2. Poor Logistics. Members are scheduled back-to-back without regard to distance between their locations. That means you are chronically late, and some members cancel their meeting with you. No-show and cancellation rates (in my experience) are about 20%. You are not compensated for any of the time associated with driving to their location, talking to them on the phone, or otherwise trying to locate them when they are not home upon your arrival. Once a member cancels, you cannot fill their slot with someone else on the same day.
3. Threat of harm. Members mostly come from low to middle class income levels. Some of them live in truly horrific living situations (no electricity, a home overrun with cockroaches, no food or running water), and others are psychologically unstable. As a female physician driving alone into a very rural area to conduct a physical exam on a male patient who is actively psychotic… this can be dangerous. You never know what or who you will face. I have had to call social services on numerous occasions and have narrowly escaped inappropriate sexual advances.
4. Limited Support. There is no guarantee that anyone from the parent company will be available via phone when you call during an emergency. I have called on several occasions during critical situations where I had to leave a voice message and was assured that “my call was very important” and someone from provider services “would get back to me within 1/2 a business day.”
5. Questionable ethics. Schedulers do not explain to the members why you are coming to their home to evaluate them. Because the schedulers seem to work on commission, they often use questionable tactics to get the members to agree to the evaluation – such as telling them that the meeting is “mandatory” and will “take 20 minutes” or is “just a wellness visit.” For this reason, many members receive you with suspicion, wondering if you’re there to try to “throw them off the Medicare plan” or are angry that they were mandated to meet with you. Lengthy conversations and apologies to set the stage for your evaluation are commonplace.
6. Payment denials and exaggerated pay potential. Evaluations must be completed meticulously or the quality assurrance reviewers will reject your forms and you will not be compensated for your work (if you, for example, forget to check a box or use a non-approved abbreviation). Although the advertisements state that some physicians complete 35-45 evaluations per week, that is nearly impossible in areas where clients are not clustered together tightly. It is an extremely misleading statement, in my experience. Apparently online reviewers agree.
7. Glitchy and costly technology. In order to save on costs, electronic evaluations can be completed via an iPad rather than paper forms. Unfortunately, the software often crashes, resulting in a return to paper in the middle of an evaluation. This ends up increasing the amount of time required to complete evaluations as your evenings are spent copying paper records into the iPad program. In addition, you are required to purchase your own stylus for data entry, as well as all the equipment required during your physical exam (e.g. blood pressure cuff, bathroom scale, ophthalmoscope, stethoscope, and more).
8. Low-budget travel and accommodations. While the agency boasts that they will pay for your accommodations and rental car, that typically translates into a room at a low-budget hotel and a Toyota Yaris with roll-down windows and no GPS.
9. The truth is hidden. The real reason for the evaluations is to help health insurers obtain larger reimbursements from the government. A physician (or NP) is required to verify all of the patient’s current medical conditions to justify their “risk score.” Medicare Advantage plans get paid more to manage patients with higher risk scores, so they are very motivated to document the complete list of diseases and conditions per at-risk senior. Patients may benefit from having an objective third party review their health record, but this is not the main goal. Also, it is unclear if the higher risk scores ultimately translate to more benefits and services for the patients.
10. Treated like a number. Sadly, my experience with my recruiter (the person who matches your availability with evaluation needs in various states where you hold a medical license) has been underwhelming. I took the time to make suggestions about how to improve the process for evaluators, but my recommendations fell on deaf ears. Not only were my phone calls and emails not returned, but when I suggested that it didn’t make sense for me to continue seeing members when I had a 66% no-show rate he simply replied, “I took you off the schedule – we have an abundance of FL doctors so it is not an issue.”
Take a look at the lovely marketing promotional images for the job:
And this video of what it’s like to do a home evaluation:
Now take a look at some photos that I took while on assignment (note: these are not actual patient homes, but are very similar to ones I encountered):
Taking a job as a Medicare Advantage evaluator was a real eye-opener. Poverty and chronic illness in America takes on a whole new light when you experience patients’ actual home environments. It’s like being a medical missionary in your own country. I’ve met patients who hadn’t seen a physician in decades, diagnosed life-threatening illnesses, and made sure that care (or case management) was initiated for countless people living on the fringes of society.
I’m glad for the experience – but think that my peers considering similar work should be told the truth about what they will be doing. Being a Medicare Advantage evaluator is not like the shiny “care anywhere” ad suggests – and “lucrative” is not exactly the right adjective for $30/hour for an MD’s time. But if you don’t mind being treated poorly by your employer, investing a lot of your own money in equipment costs, and putting your life at risk in dangerous home environments – you may actually do some good for the forgotten, frail elderly of this nation, (while helping middle men like Censeo Health to profit from health insurance behemoths, alas). Now you know the truth behind the advertising and can make an informed decision about whether or not you’d like to sign up for this work.
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As a physician who openly despises many aspects of current EMRs (see “How An EMR Gave My Patient Syphilis” or “The Medical Chart: Ground Zero For The Deterioration Of Patient Care” ) I recognize that they are here to stay. And so, since we’re all stuck with these digital middlemen, I have some suggestions (based on popular social media platform functionality) for making them better.
1. Likes. Healthcare providers should be able to “vote up” an excellent note in the medical record. Let’s face it, not all doctors are equally good at documentation. Untold hours of our time are spent trying to cull through pages of auto-populated, drop-down-box checks to figure out what’s actually going on with a patient on a particular day. Once in a while you stumble upon some comprehensive free text that a physician took the time to type after a previous encounter, and suddenly everything becomes clear. If there were a way to flag or “like” such documents, it would help other readers orient themselves more quickly to a patient’s history. A “liking” system is desperately needed in EMRs and would be a valuable time saver, as well as encouragement to physicians who document notes well. Hospitals could reward their best note makers with public recognition or small monetary bonuses.
2. #Hashtags. Tagging systems are sorely lacking in medical records systems, which makes them very difficult to search. Patients make multiple visits for various complaints, often with numerous providers involved. If physicians had the ability to review notes/records unique to the complaint that they are addressing, it would save a lot of time. Notes could be tagged with keywords selected by the author and permanently recorded in the EMR. This would substantially improve future search efforts. Even if the EMR generated 10 search terms (based on the note) and then asked the physician to choose the 3 most relevant to the current encounter, that would be a step in the right direction.
3. Selfies. Medical records would benefit from patient-identifier photographs. In a busy day where 20-30 patients are treated and EMR notes are updated after the patients have gone home, a small patient photograph that appears on each documentation page will serve the physician well in keeping details straight. Patients should be able to upload their favorite portrait to the EMR if the standard one (perhaps taken during the intake process) is not acceptable to them. In my experience, nothing brings back physical exam and history details better than a photograph of the patient.
4. Contextual links. All EMRs should provide links to the latest medical literature (on subjects specifically related to the patient’s current diseases and conditions) in a module on the progress note page. UpToDate.com and other reference guides could easily supply the right content (perhaps based on diagnosis codes). This will help physicians practice evidence-based medicine and keep current with changes in recommended treatment practices.
5. Microblogging. Sometimes there are important “notes to self” that a physician would like to make but don’t need to be part of the official medical record. EMRs should provide a free-text module (like a digital sticky note) for such purposes. These sticky notes should not be admissible in court as part of the medical record, and should not be uploaded to the cloud. Content included in these notes could include social information (patient’s daughter just had a healthy baby girl), hunches (patient looks slightly pale today – will check H&H next time if no change), and preliminary information (remember to review radiology result before calling patient next Tues).
It is my hope that EMRs will slowly adopt some best practices from top social media platforms. After all, if millions of users are effectively using voting, tagging, linking, searching and imaging in their daily online lives, it only makes sense to capitalize on these behaviors within the constraints of the medical environment. Maintaining strict confidentiality and appropriate professional boundaries (often missing in the social media world at large) is certainly possible with EMRs. Let’s build a better information capture and retrieval process for the sake of our patients, and our sanity.
At least one EMR is already providing #3 and #5 as part of its software: see MDHQ.com Are you aware of any others already implementing these ideas?