I was talking to a fellow physician about a mutual patient. I had information that would help him in their care and he was taking the unusual step of asking me for my information. I was impressed.
“Could you fax me those documents?” he asked. ”Here’s my fax number.”
I scrambled to get a pen to write down his number. Then I had a thought: “I could email you those documents much easier. Do you have an email address?”
Silence.
After a long pause, he hesitantly responded, “I would rather you just fax it.” He said no more. Read more »
I’ve been following the career trajectory of Dr. Gordon Moore since I first became aware of his low-overhead, high-tech model of medical practice. He’s come a long way since the AAFP first interviewed him in 2002. I had the chance to catch up with him at the recent Health 2.0 conference in San Francisco, and we discussed the future of primary care and a practice model that I believe in (I just joined DocTalker Family Medicine myself!) Here’s our peek into our healthcare crystal ball…
Dr. Val: Tell me about what got you interested in creating a new practice model for primary care?
Moore: I came into healthcare with a somewhat Pollyannaish vision of reducing suffering and improving health. Without any docs in my family, I had no understanding of what it meant to actually practice. About 5 years after residency, I realized that there was an increasing disparity between my vision of practicing medicine and its reality. At that time I joined a quality improvement initiative at the University of Rochester, and we looked at increasing efficiency in primary care, including creating the idealized design of clinical office practices. Read more »
Health IT is valuable in many ways and I do believe it will revolutionize how we practice medicine. However, we’ve got a long way to go yet, especially in auto-translating English into other languages. This short exercise in English-Spanish translation (through a computer software program) reminds me of how far off “seamless” health technology really is…
(My mother is fully bilingual in Spanish and English and decided to test the auto-translator service with a sentence from a book. Here is the result:)
ENGLISH: He popped a deep-fried sardine into his mouth and washed it down with a few swallows of beer.
LITERAL TRANSLATION OF SPANISH RESULT: He punctured a sardine fried deep in his mouth, and he laundered it near the bottom along with some swallows (referring to the birds) made of beer.
Like many other people, Ms. Krinsk thought that her prescription information was private. But in fact, prescriptions, and all the information on them — including not only the name and dosage of the drug and the name and address of the doctor, but also the patient’s address and Social Security number — are a commodity bought and sold in a murky marketplace, often without the patients’ knowledge or permission.
But given the money involved, I’m afraid it isn’t.
But with the pharmaceutical industry soon to release $150M dollars of ads promoting health reform as they cozy up to Congressional leaders, the conflicts of interest for patient’s privacy are staggering. Further, the promotion of the electronic medical record, personal health records, and ultimately, cloud computing (where no one will know where health data resides), are firmly part of the health reform landscape.
Now before people think I’m totally against the EMR, let me be candid: I’m not. It does facilitate care and is an incredible means of communication between physicians and laboratories and pharmacies and the like. When used properly, they are miraculous.
But the risks of losing information remain huge. Certainly, the above referenced New York Times article notes that safeguards are supposed to be enacted to prevent this wholesale marketing of your health data.
But suddenly, we learn of a White House snitch line where they will collect e-mails of people who might be spreading “misinformation” about the health reform efforts underway. (Thanks to my previous blog post, I am happy to report I’ve been reported! ;)) But this occurs at a time when privacy issues in health care must be seen as paramount and electronic medical records protected as secure.
Ooops.
So now we have a White House eager to build a snitch line as they cozy up to pharaceutical interests that are already selling personal information from prescription data, all while trying to promote the security of electronic medical records to the masses.
Who are they kidding?
But then, shucks, just think of the marketing possibilities for the government:
And lest people think I’m too partisan (who me?), the Republicans with their travel junkets aren’t any better.
Sheesh!
-Wes
Reference: White House blog with snitch e-mail link at flag@whitehouse.gov .
*This blog post was originally published at Dr. Wes*
Just as “all politics is local”, so is all medical care personal. One patient; one physician; one moment; one decision. And in this era of balanced physician and patient autonomy, that decision often is an informed joint decision. Many patients now make serious efforts to learn about their conditions both before and after visits to their physicians. Many physicians welcome such informed patients and willingly discuss comparative effectiveness of the available diagnostic and therapeutic options. However, a frank discussion about the comparative costs and charges for the options, whether they be to the insurance company, Medicare, Medicaid or out-of-pocket for the patient, is usually missing.
Many health economists insist that the medical marketplace does not behave like other markets and believe it is fruitless to expect market principles to usefully inform the medical arena. That bias is true in emergencies,
operating rooms or intensive care units, and with patients who are mentally disabled.
Such behavior does not have to persist in an outpatient setting. In my book Severed Trust: Why American Medicine Hasn’t Been Fixed (Basic Books, 2000, paperback 2002), I presented the concept of “the economic informed consent.”
I believe that every patient who is mentally competent and in a non-emergency situation should be informed of the cost of a proposed diagnostic or therapeutic procedure or product, before it is “ordered.” This includes referral to another (often more specialized and costly) physician, no matter who pays the bill. The costs should all be discussed IN ADVANCE decision. This discussion should include whether it is worth it and
whether there a less expensive good alternative.
A recent NPR/KFF/HSPH survey reported that 55% of Americans believe that their insurance company should have to pay for an expensive treatment, even if has not been proven to be more effective than a less expensive
treatment. This attitude underlies the ruling convention, “if insurance will cover it, do it,” that lies at the root of our problem of health care cost inflation. No one is held accountable.
If we as a country could widely apply the “economic informed consent,” physicians and patients would become educated together. They could both become wiser shoppers for the most cost-effective diagnostic tests,
prescribed drugs, and specialists.
With an “economic informed consent,” physicians and patients can reset attitudes toward a healthy concern for the total costs or charges, stifling the usual knee-jerk response, “if the insurance covers it, do it.” No one
knows whether this approach, diligently applied, would actually cut down on wasteful spending, such as choices that drive huge geographic variations, but we do know that pricing an automobile, an airplane ticket, a dinner or a bottle of wine does affect consumer decisions. Why not try it for medical charges as well? Current sweeping proposals for health system reform all state that there must be “cost control” but offer little likelihood of delivering real cost savings.
Now is the time for the US Health Information Technology Initiative to create inter-operative systems that would provide the data to support widespread use of the “economic informed consent” in a timely fashion and
let the medical marketplace speak. Knowing the cost of a medical decision in advance should become a part of a new “Patient’s Bill of Rights”. In a medical care decision, it is the right of a patient to know “who pays whom
how much for what.” All of us in health care laud “transparency”–let that include economic transparency.
I filter through progress notes looking for the few sentences different from the day before, only to find them sandwiching pages and pages of electronically-produced babble dutifully and automatically mass-reproduced in every note. I wonder, has anyone ever looked retrospectively at the mess created by this process developed to assure doctors were doing what they said they were doing? Ironically, I find we’re rarely reading most of what we re-create each day.
But we’re sure good at following the rules.
Next.
I now see prescription refills for each and every bottle of prescriptions ever filled by a patient, the date a patient filled it, and how many pills they received with each prescription. I’m not sure why. I sat awestruck in clinic yesterday when the list extended 94 pages, double-spaced, since January, 2009. No one, and I mean no one, filled that many prescriptions, did they? Or did they? Am I supposed to correct that list? Oh, by the way dear referring doctor, my note’s at the bottom of that listing.
Next.
I get pre-surgical notifications, even though I was the one to notify everyone else about the need for admission, just so I can click on the patient’s name again, lest it not appear I’m not doing enough, I guess.
Next.
I get EKG results forwarded for me to sign electronically, even though I’ve already read them, and signed them, by hand, on the EKG. I get notified again that the order I entered for that EKG now has a result, and I have to click on that to tell the computer, “I know.” But that, you see, is not enough. I must also log in, review, and sign off on my EKG’s on the EKG server, too. After all, I’m responsible, and it’s all about quality.
Quality three times over.
Now, multiply that same process for each and every other test I have ordered.
Next.
I see orders for things I’m not sure I ordered, just to be sure I’m responsible, and watching, literally hundreds of times per day.
Next.
I get e-mails and electronic notifications, and electronic communications, as if I know the difference.
Next.
I bypass nursing notes that are mere QA checklists and say nothing about the patient, except that a nurse was there last night.
Next.
I feel guilty entering data as I talk to my patient while serving my electronic master. Yet I find the stakes are high to assure accuracy and timeliness in clinical electronic reporting. After all, you never hear the bullet that hits you.
Next.
I go home on call, am paged, and reprimanded by a patient who wonders why I can’t look up their medication list on-line, even though I’m standing in the grocery store.
Next.
Worst of all, I find myself sending myself messages, just to make sure I do something tomorrow that I could not get done today.
Killing me softly …
… with information overload.
*This blog post was originally published at Dr. Wes*
I attended the 29th annual Management of Change (MOC) Conference with Dr. Val. The conference is sponsored by the American Council for Technology and the Industry Advisory Council. MOC brings together government and industry leaders to share knowledge, collaborate, and develop actionable technology management strategies. As a physician, attending this conference for the first time, I assumed a great deal of the conference topics would be over my head and in very “techie” terms. My hope was to get a glimpse of some of the technology solutions the government was considering as they relate to health care IT.
Vivek Kundra, first Chief Information Officer of the United States, addressed the audience early in the day in language that even a doc could understand. He spoke about the need to simplify government, and connect people to solutions, instead of “endless bureaucracies.” The same of course goes for medicine. How great would it be to connect our patients to systems that actually had interoperable medical data?
I was able to catch up with Mr. Kundra after his talk for a few minutes and ask him how technological simplification would apply to physicians such as myself, operating in a haphazard infrastructure with varying PAC systems, EMR’s and paper charts. He said the key would not only be investing in technology, but investing in training healthcare personnel to master new technologies. He acknowledged that different generations of physicians would embrace technology differently, but ultimately, if a physician says he “can do a better job on paper” then we have a problem.
I was very impressed by Mr. Kundra’s answer namely because it was so insightful for a man who’s expertise lies primarily in the technology field. He does not come from a healthcare background, and yet had hit the nail on the head. There has been so much talk about HIT being the “key” to cost savings and the next “breakthrough” in medicine. With very little discussion on how physicians feel about it. For some docs - particularly those that come from an older generation - the thought is quite terrifying. They are happy with their paper charts and manual dictations. Health technology is almost viewed as an impediment to those set in their ways, and accustomed to a system that has worked for them and their patients for years. This upheaval will not come without it’s challenges even after we find the best technologies for the tasks at hand. It will be imperative for government leaders to understand that the mission of HIT implementation may be just as difficult as finding the technology solutions they are currently seeking.
As Mr. Kundra and his team embark on this huge task, it will be important for physicians and health care personnel to engage with the government and serve as a guide for what docs need from technology, and what will and will not work for our patients. I hope next year’s conference is attended by more physicians such as myself and Dr. Val.
There are some things that Electronic Medical Records do well and there are some things that Electronic Medical Records do poorly. To say that I need Electronic Medical Records to help me type is nothing short of ridiculous. Unfortunately, when engineers meet computer programmers and try to help health care professionals type in the health care record in the name of “safety,” the results can torment those they’re trying to help.
Take auto-spelling, for instance. I have the nasty habit of typing “Lungs: Claer to A&P” and marvel at the auto-correction feature automatically correcting my typing to “Lungs: Clear to A&P.” This is an example of the wonders of electronics.
But when I type “DC Cardioversion” and the computer won’t left me type “DC” because it wants to know if I mean “discharge” or “discontinue,” the computer becomes intrusive, obstructive, and performs a service that should be right up there with water-boarding. I mean, is someone really going to mistaken that I mean “Discontinue cardioversion” or “Discharge cardioversion” when I’m typing my operative report? I could see this being a problem in the order-entry portion of the software, but when I’m typing by progress note or operative note?
Please.
Even better are the wonderfully useful letters “MS.” These might mean “magnesium sulfate,” “mental status,” mitral stenosis, “MS Contin,” “multiple sclerosis,” “musculoskeletal,” “Ms.,” or maybe even “Mississipi.” So, instead of being able to type a logical sentence without interruption, the doctor finds that that a drop-down pick list prevents those magic letters from being typed. It seems the chance that a nurse will wonder if you’re prescribing a drug in a southern state trumps the ability to enter a simple sentence on the computer. This is, after all, how we’re preventing medical errors.
But I wonder if these computer engineering road blocks are doing something much more insidious and detrimental to our health care delivery of tomorrow: like devaluing independent thought, reason, permitting the subtleties of context, and common sense.
Does the “Art of Medicine” really exist, or perhaps more importantly, can it do so in the computer age?
Computers are both the boon and the bane of medicine. Electronic medical records (EMRs) are excellent for retrieval of information about labs, medications, and past medical history of our patients. These records are much easier to access than our old paper charts. However, I feel that the Achilles Heel of these advances lies in the fact that physicians are so busy inputting information into their computers that they do not spend enough time communicating with the patient.
Communication with your patient is the epitome of the Art of Medicine. It is vital that physician and patient understand each other. This includes not only what the patient says but what they mean. This takes time, a commodity which is in short supply in the age of EMR. One should always remember a basic caveat about computers, which is, “garbage in, garbage out.” If wrong information is fed into the computer, it doesn’t matter what algorithm that you use because you will be following a false trail.
Computerization of medicine will lead to great advances if it is implemented properly. However, the way things are presently being done cheats the patient out of the most important part of the doctor patient relationship - time to communicate. I always remember the precept advanced by Sir William Osler, the father of modern medicine, “Listen carefully doctor, the patient is giving you the diagnosis.”
The combination of the computer age along with the time to listen to the patient and to accurately define their problem will indeed lead to a new age in medical care, but to ignore one or the other is not to fulfill our obligation to our patients.
Paul Ravetz is a family physician.
*This blog post was originally published at KevinMD.com*
Electronic Medical Records are coming. The economic stimulus bill (furious spinning kittens notwithstanding) assured this.
Under the terms of the bill, CMS will offer incentives to medical practices that adopt and use electronic medical records technology. Beginning in 2011, physicians will get $44,000 to $64,000 over five years for implementing and using a certified EMR. The Congressional Budget Office projects that such incentives will push up to 90 percent of U.S. physicians to use EMRs over the next 10 years.
Practices that don’t adopt CCHIT-certified EMR systems by 2014 will have their Medicare reimbursement rates cut by up to 3 percent beginning in 2015.
There will be even more money for implementation. We look forward to our checks (and are not counting on them yet).
Now it is time for the flies to start gathering. Wherever there is lots of money, “experts” pop up and new products become available that hope to cash in. Doctors, who are never lauded for their business acumen, will be especially susceptible to hucksters pushing their wares. It seems from the outside to be an simple thing: put medical records on computers and watch the cash fly in.
Anyone who has implemented EMR, however, can attest that the use of the word “simple” is a dead giveaway that the person uttering the word in relation to EMR is either totally clueless or running a scam. It’s like saying “easy solution to the Mideast unrest,” “obvious way to bring world peace,” or “makes exercise easy and fun.”
Run away quickly when you hear this type of thing.
Just like becoming a doctor is a long-term arduous process, EMR implementation happens with time, planning, and effort. It’s not impossible to become a doctor, but it isn’t easy. With EMR adoption, the most important factor in success is the implementation process. A poorly implemented EMR isn’t simply non-functional, it makes medical practice harder. A well implemented EMR doesn’t just function, it improves quality and profitability.
How do I know? Our practice ranks very high for quality (NCQA certified for diabetes, physicians are consistently ranked high for quality by insurers), and we out-earn 95% of other primary care physicians. EMR allows us to practice good medicine in a manner that is much more efficient.
So how’s a doc to know who to trust? What product should he/she buy and whose advice about implementation should they follow? There are many resources out there. Here are a few I think are especially worthwhile:
Buy a product that is certified by Certification Commission for Health Information Technology. CCHIT is a government task force established to set standards for EMR products. Its goal is to allow systems to communicate with each other and enable more interfaces in the future. The bonuses for docs on EMR are contingent on the system being CCHIT certified (think of it as something like the WiFi standard).
Several professional IT organizations have programs to improve EMR adoption, including HIMSS and TEPR.
Austin Merritt has written a good article of advice on his website Software Advice that underlines the importance of implementation.
The best advice I can give, however, is to visit a doctor’s office who is using an EMR successfully. This office should be as close in make-up to your office as is possible. You should be able to look at how they do it and see yourself in that situation. Never buy a product before visiting at least one office like this (no matter how good the sales pitch). When you visit, make sure you ask them about the implementation process. How did they do it and how hard was it?
Which EMR do I recommend? Remember, I have been on EMR for over 12 years, so haven’t had much of a chance to shop around. You hear raves and horror stories with every product. Here is some basic advice:
Get a solid CCHIT-approved brand that has been around for a while
Don’t pay as much attention to price as you do function. Since the EMR will be absolutely central to the function of your office, it is a dumb mistake to overly-emphasize cost.
Realize you are paying for a company, not just a product. It is not like buying a car, it is more like having a child or getting married. REALLY research that side of things. A good EMR with a bad company behind it should be avoided like the plague.
See how connected the user-base is as well. A solid user group will do much to make up any deficiencies in the product and/or company.
So much time is spent shopping over EMR products, but buying an EMR is like being accepted into Medical School; your work is just beginning. That’s OK, because like medical school, the effort put in gives a very worthwhile product.
Update From Haiti: Despair Sets In And Women Consider Suicide
Audio clip: Adobe Flash Player (version 9 or above) is required to play this audio clip. Download the latest version here. You also need to have JavaScript enabled in your browser.
Watch CBS News Videos Online Last week’s CDC report Health United States confirms that Americans are increasingly turning to medications scans and procedures to improve their health. Exercising eating right and weight loss not so much. Don’t get me wrong. I love technology as much as the next guy. Maybe…
I am one who loves medical history and Genius On The Edge the bizarre double life of Dr. William Stewart Halsted was a captivating read. For those who don t know Dr. Halsted is known as the Father of Surgery and practiced medicine after the civil war. Written by author…
I received a free copy of the book Genius on the Edge The Bizarre Double Life of Dr. William Stewart Halsted by Gerald Imber MD a week ago. I have enjoyed reading it. The book is the biography of Dr Halsted but also gives you a glimpse into the life…
In Francis Peabody famously said The secret of the care of the patient is in caring for the patient. A new book by Norman Makous MD a cardiologist who has practiced for years is a cogent reminder of that principle. In Time to Care Personal Medicine in the Age of…
