Hospital Scenes: That’s One Dedicated EMR
Even when it crashes:
(it says “Cannot Quit”).
*This blog post was originally published at GruntDoc*
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Healthcare Reform Views From A Flaming Moderate
I am a flaming moderate. Yes, I know that is an oxymoron but the fact remains that I am both passionate and moderate in my political opinions.
And I am in the mood to rant, so beware.
Living in the deep south, I often seem like a radical communist to those I see. I frequently get patients asking questions like “So what do you think about Obama’s plans to socialize medicine?”, or “I wanted to get in here before Obama-care comes and messes things up.” I usually smile and nod, but find myself getting increasingly frustrated by this.
The house is burning down, folks. Healthcare is a mess and desperately needs fixing. How in the world can someone cling to old political yada-yaya-yada when people are dying? I am not just talking about the conservatives here because to actually fix this problem we all have to somehow come together. A solution that comes from a single political ideology will polarize the country and guarantee the “fix” to healthcare will be one constructed based on politics rather than common sense.
No, this doesn’t frustrate me; it infuriates me. The healthcare system is going to be handed over to the political ideologues so they can use it as a canvas for their particular slant. In the mean-time, people are going to be denied care, go bankrupt, and die. Yes, my own livelihood is at stake, but I sit in the exam room with people all day and care for them. I don’t want to be part of a system that puts ideology above their survival.
So here is what this radical moderate sees in our system:
- The payment system we have favors no one. Every single patient I see is unhappy with their health insurance to varying degrees.
- Stupid and wasteful procedures shouldn’t be reimbursed. This is business 101; if you don’t control spending, you will not be able to sustain your system. This means that we have to stop paying for procedures that don’t do any good. Some will scream “rationing” at this, but why should someone have the right to have a coronary stent placed when this has never been shown to help? Why should we allow people to gouge the system for personal gain in the name of “free market”? I got a CT angiogram report on patient today who has fairly advanced Alzheimer’s disease. I twittered it and the Twitter mob was not at all surprised. These things happen all the time. The procedures do no good and cost a bundle. The procedure done today probably cost more than all of the care I have given this patient over the past 5 years combined!
- The government has to stop being stupid. Why can’t I give discount cards to Medicare patients? Why can’t I post my charges, accept what Medicare pays me, and then bill the difference? The absurdity within the system is probably the best argument against increased government involvement. Who invented the “welcome to Medicare physical??” I never do it because the rules are utterly complex and convoluted. If the rules can be this crazy now, how much worse will it be when the government takes over? If my medicare patients are confused now, how much more will we all be if the government grabs all of the strings?
- The money is going somewhere. In the past 10 years, my reimbursement has dropped while insurance premiums have skyrocketed. There are more generic drugs than ever and I am no longer able to prescribe a bunch of things that didn’t get a second-thought 10 years ago. Hospitals stays were longer and procedures were easier to get authorize. So where is the money going?? We do know the answer to this question – there is no single culprit. Drug companies were to blame for a while, but now they are going to the dogs; and yet the rates aren’t dropping. The real problem is that there are far too many people trying to capitalize on the busload of money in healthcare. Shareholders, CEO’s, and simple corporate greed has bled money out of the system like a cut to the jugular.
- Docs have to stop being idiots. We like our soap boxes to rant against EMR, malpractice lawyers, drug companies, and insurance companies. We stand on different sides yelling our opinions but don’t come up with solutions. Instead of doing what is right for our patients, we join the punching match of politics. Is EMR implementation important? Duh! There is no way to fix healthcare without it. But the systems out there are designed by engineers and administrators and don’t work in the real life. So why can’t we computerize ourselves? Every other industry did. Why must we cling to the archaic paper chart because we don’t like the EMR’s out there? Aren’t we smart people? Aren’t we paid to solve problems? Stop throwing darts and start finding solutions. Med bloggers are terrible in this – they rant constantly against EMR, but don’t ever say what would work. It’s fun to criticize, but nobody wants to propose an alternative.
- We need to get our priorities right. Healthcare is about the health of the patient. Yes, it is a job for a lot of people. Yes, it is an investment opportunity. Yes, it is a good thing to argue about – whether it is a “right” or not. Yes, it is a major political battleground. But in the end, these things need to be put behind what is most important. As it stands, we are more passionate about these other things than we are about the people who get the care. In the end it is about making people well or keeping them that way. It is about saving lives and letting people die when it is time. If we were all half as passionate about what is good for patients (and we are all patients) as we are about these other issues, we wouldn’t have half of the problems we have.
As a flaming moderate I get to offend people on all sides. We need to fix our system. It is broken. It is not a playground for those who like to argue. It is not a place to be liberal or conservative. This is our care we are talking about, not someone else’s. The solution will only come when we all come to the table as potential patients and fix the system for ourselves.
Is it easy? Heck no. This rant is not meant to show I am smarter than the rest of you; it is meant to get all of us away from the other issues that make any hope of actually fixing our problem remote. Given the fact that we all are eventually patients, our political posturing and plain stupidity may come back to haunt us. No, it may come back to kill us.
*This blog post was originally published at Musings of a Distractible Mind*
Hot Topics In Healthcare Reform: A Primer
For those of who believe there is a pill for every ill, the recent flurry of legislation and ensuing debates on health care reform may be just too big a pill to swallow.
You’ll need a very large glass of water for sure.
“There’s a lot to consider and not everyone is going to like everything about this legislation,” Rep. Lois Capps (D-CA) told participants at Avalere Health’s conference on Raising the Bar: Payment Reform and CV Disease on Friday, June 12 in Washington. Capps, a 20 year veteran school nurse, co-chair of the Democratic Heart and Stroke Caucus and member of the House Energy & Commerce Health Subcommittee describes the pending legislation in terms of “choice” and “a balance” but readily admits that finding a way to pay for it will be difficult.
For those who might not feel up to speed on the latest buzz on health care reform, here’s a quick primer:
Public Option. To cover the 47 million uninsured or underinsured Americans, the President is asking for a public plan that would compete within the insurance market place either directly on cost, or indirectly with clout. Supposedly, this plan (yet to be included in the Senate HELP health reform legislation introduced last week but rumored to be coming in the markup) will be subject to the same rules and regulations of the private health insurance market. It could be an extension of Medicare, Medicaid or a hybrid of approaches involving capitation and integrated systems for physicians and hospitals.
The debate about whether or not to introduce a new public option to the current health insurance system involves more than a sense of fairness or simply closing the gap. The private insurance business is strongly tied to state regulations and competitive forces that will remain as long as 15% of Americans purchase their insurance out of pocket and another 40% have insurance through employment . Designing the right form of public assistance that can compete with private insurance but not control the market place is surely to reflect the strong differences between political parties.
Centralists in Congress, namely Sen. Kent Conrad (D-ND), have proposed co-ops as a third approach between a public option and the status quo. Co-ops are membership-owned and operated non-profit organizations that adhere to state laws for health care coverage and provide health insurance for individuals and small businesses. Reaction has been mixed but some believe co-ops will hit the right balance of competition and public assistance needed for passage in the Senate.
Comparative Effectiveness. Comparative effectiveness research seeks to compare the clinical effectiveness of two alternative therapies for the same condition. It’s rooted in the idea that our system of paying for the volume (e.g., “fee-for-service”) should be replaced with payment for effectiveness and value that is based on the best science possible. Recent examples of comparative effectiveness research include trials comparing bare metal coronary stents to drug-eluting stents and comparing older versus newer drugs for treatment of schizophrenia. All this can be extremely valuable to clinicians and patients trying to decide between alternative courses of treatment. And to the extent that comparative effectiveness research improves the quality of care, it can also reduce costs.
But clinical data alone cannot reflect patient preferences or whether a treatment course for the overall population is the best one for an individual. The hot button here is how to encourage clinical research that can help physicians and patients make the best treatment choices yet safeguard it from being used by insurance companies and the government to deny coverage or set payment. What, exactly, will be compared needs close scrutiny.
Accountable Care Organizations (ACOs). An ACO is a combination of one or more hospitals, primary care physicians and possibly specialists, who are accountable for the total Medicare spending and quality of care for a group of Medicare patients. Various carrots and sticks are being discussed, but the idea is to control Medicare spending and improved quality of care. While most physicians recognize the need to move away from Medicare’s fee-for-service approach, the incentives and infrastructure needed to coordinate among providers isn’t apparent. What about rural areas where coordination of care is a misnomer? This may be a hot topic for systems change, but practitioners are skeptical.
Patient-Centered Care. It’s hard to imagine that the American College of Cardiology felt the need to launch a new initiative, the “Year of the Patient” or the British Medical Journal depicted tango dancers on its cover story, “Partnering with the Patient” but re-infusing the health care debate from the patient’s perspective is long overdue. Look for it in every piece of legislation, new commission and advisory group. Raising the voice of a few on a plum commission or panel discussion is a laudable start, but we’re all, at one time or another, patients. We’re all consumers of health care and drawing upon our own experiences to improve our professional stance will be necessary.
Gateways. The Senate HELP Committee’s legislation introduces the concept of “gateways” or “exchanges”, a clearinghouse of sorts on a state level to help consumers parse through insurance plans and public services. The program would be optional for states for the first six years then federal compliance would prevail. Organizations such as Kaiser Family Foundation have already established online “gateways” (www.healthreform.kff.org) to inform consumers wanting to know more.
Health reform is coming fast and furious. On Monday, June, 15, the Congressional Budget Office is expected to release their projections on what it will take to pay for such massive reforms. Hospitals and physician groups are deeply concerned about cuts in Medicare payments – estimated by the President on his weekend radio chat as an additional $313M on top of the $309M included in the Administration’s FY2010 budget.
Further legislation will be released this week; keep an eye on the Senate HELP Committee, Senate Finance Committee, House Energy & Commerce, House Ways & Means, and House Education and Labor.
There’s much more to health reform than covered here. I encourage you to find a passion point of entry and share your insights.
And get ready to swallow a very big pill.
Here’s a quick list of what’s hot in health care reform:
- Public Option
- Electronic Medical Records
- Elimination of pre-existing exclusion
- Patient-Centered Care
- Accountable Care Organizations
- Payment based on value not volume
- Integrated health delivery systems
- Federal Health Board
- Transparency in data, costs and outcomes
- Personalized health care/personalized information
- Chronic care models/Transitional Care Models
- Prevention and wellness programs
- Comparative Effectiveness
- Payment reform/Medicare cuts
- Shared decision making
The Real Reason Why Doctors Don’t Want To Adopt EMRs, And What To Do About It
Have you ever been ignored by someone who was texting or otherwise engaged in a digital conversation? Did you feel that the person was being rude and unresponsive to you? If your answer to both of these questions is “yes” then you will understand the real reason why some doctors don’t want to adopt electronic medical records systems (EMRs).
As sappy as this may sound, most physicians were drawn to medicine because they wanted to help people, save lives, and improve the quality of life for those suffering from disease. Even after we’ve been beaten up by our training programs, and weighed down by debt and the mountains of paperwork required by a broken healthcare system, most of us still retain that do-gooder kernal inside us – we genuinely care about our patients.
And so because we care, we know instinctively that the human side of medicine – the attentive listening, the visual cues, the continued eye contact, and the careful history and physical exam – is critical to our profession. The problem we have with EMRs is that they often interrupt the sensitive and intuitive parts of what we do. EMRs and other digital “tools” designed to make our work more efficient, may do so at the expense of the human connectedness our patients deserve and need.
Most EMRs, as they exist today, are not designed to bring patients into the conversation. In order to maximize efficiency, the physician must type while the patient is talking – usually turning their gaze and even their whole bodies away from the individual or family. Those of us who feel that this behavior is socially inappropriate will take a verbal history from the patient and then type it up from memory later – this creates more work than if we’d simply taken notes during the conversation in a paper-record, and may introduce recollection bias if we do our typing at the end of a long day of seeing many patients.
There is certainly a generation gap in terms of EMR adoption (as my friend Dr. Geeta Nayyar has noted) – our new crop of doctors are very comfortable with EMRs and wireless tools of various kinds, while the “older” doctors are often highly resistant to adopting a digital system. But before we label senior physicians as “obstructing progress” – let’s look beyond the technology issues (yes, it takes time to learn how to do something a different way) and at some of the emotional reasons why physicians don’t like what EMRs do to their patient relationships.
Time and again I’ve heard my peers (who use EMRs in hospitals) say that they feel that they spend most of their time “talking to the computer” rather than the patient. They are wracked with guilt about this, and have actually lost a portion of their “job satisfaction” as a result. They know that the digitization of healthcare has robbed them of the luxury of full history and physical exams, conducted in an uninterrupted face-to-face encounter with their full attention on the patient. They feel like a robot – like a mere collection of algorithms used to process people in an “evidence based” framework. And the patients – they report that their doctors are hurried, uncaring, and potentially replaceable with a robot.
In my opinion, EMR manufacturers must understand the collateral damage that their products can do to the physician-patient relationship and create EMRs that engage patients in the physician encounter. I have seen at least one prototype product that is trying to do this (and there may be many more – it’s difficult to keep up with all the new innovations, so please leave a comment about other products that you know of), Microsoft’s Surface. Surface allows the physician and patient to sit together at a table with a screen embedded in its top. The physician can bring up lab results, radiology images, and medical records to discuss them with the patient so they can see it at the same time. I really like this concept, since it facilitates electronic record keeping while engaging the patient in the encounter.
When EMR vendors and civil servants bemoan the slow technology adoption rates of physicians, I urge them to recognize that there is more at play than just “resistance to change.” There is a resistance to dehumanizing doctor-patient interactions, to turning one’s back on a crying patient to type notes on a laptop, to spending more time “talking to a computer” than talking to a patient. That resistance is actually a good thing – it means we still care, we have hearts, we are human.
Now, to get physicians to adopt EMRs – don’t use a stick (“adopt our EMR or we’ll fine your practices”) use the younger generation of physicians (already comfortable with technology) to teach the older ones how to integrate digital record keeping into their workflow. During that interaction, I believe the senior physicians will be able to teach the junior ones a lot about the art of humanizing their patient interactions, while the younger ones train them about the technical process of incorporating EMRs into their own workflow.
In summary, EMR adoption is slow not just because of cost and technical skills barriers, but because of the potential dehumanizing effect they can have on medical practices. Senior physicians may understand this risk better than junior ones, and should be admired for their desire to maintain fewer barriers in their relationship with patients. EMRs created with the ability to include patients in the conversation can reduce the potential social damage they often introduce in patient encounters. Peer-to-peer training is valuable in improving adoption rates, teaching junior physicians the social etiquette important in a caring doctor-patient relationship (and to maintain the art of listening and observing), and helping senior physicians learn how to use technology to achieve the tasks they currently complete by other methods.
Vivek Kundra: Training Physicians To Use EMRs Is The Key To Adoption
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.
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